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ABDOMINAL     SURGERY 


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V 


ABDOMINAL 
SURGERY 


BY 


J.    GREIG    SMITH,    M.A.,    F.R.S.E. 

Surgeon  to  the  Bristol  Royal  Infirmary 

Lecturer  on  Surgery,  Bristol  Medical  School 

Late  Examiner  in  Surgery,  University  of  Aberdeen 

Fellow  of  the  Royal  Medical  and  Chirurgical  Society,  London 

Honorary    Felloiv    of  the   American    Society    of   Obstetricians   and 

GyncBcologists,  &c. 


XTbirC)    BDition 


PHILADELPHIA 
P.     BLAKISTON,     SON     &     Co. 

IOI2     W'ALNl'T     STREET 


All  rights  reserved. 


PREFACE    TO    THE    THIRD    EDITION. 


In  this  Edition  I  have  endeavoured  to  improve  the  work  in 
detail,  by  the  Hghts  of  advancing  general  knowledge  and 
increased  personal  experience.  Statistics  have  been  brought 
as  closely  as  possible  up  to  date ;  several  novel  proceedings 
and  modifications  have  been  described,  and  a  few  new  en- 
gravings have  been  introduced.  The  general  plan  of  the  work 
remains  unchanged. 

I  desire  again  gratefully  to  acknowledge  the  very  flattering 
reception  which  has  been  given  to  the  work. 


Clifton,  Bristol, 
October,  1889. 


Digitized  by  tine  Internet  Arcinive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/abdominalsurgeryOOsmit 


PREFACE  TO  THE  SECOND  EDITION. 


The  very  rapid  sale  of  the  first  edition  took  me  unawares,  and 
the  work  has  been  in  consequence  for  six  months  out  of  print. 
Delay  in  the  production  of  the  second  edition  will  be  excused 
on  the  plea  that  time  as  well  as  labour  were  necessary  to  bring 
the  work  fully  up  to  date,  and  to  make  certain  desirable 
additions  and  improvements. 

The  advances  made  in  the  practical  surgery  of  the  abdomen 
in  the  few  months  which  have  elapsed  since  the  work  was  written 
are  truly  astounding.  For  every  operation  some  improvement 
has  had  to  be  chronicled,  and  several  new  operations  have  been 
added.  The  whole  subject  of  the  Reparative  Surgery  of  the 
abdomen,  being  now  placed  on  a  basis  which  is  comparatively 
permanent,  has  been  elevated  to  the  dignity  of  an  independent 
section.  This  section  is  practically  a  new  one.  In  deference  to 
the  opinion  of  certain  reviewers,  and,  it  must  be  confessed,  in 
harmony  with  a  personal  feeling,  a  new  section  on  Supra-pubic 
Cystotomy  has  been  introduced.  Among  the  minor  additions 
may  be  mentioned  Keith's  mode  of  treating  the  pedicle  in 
ovariotomy ;  Cervical  Amputation  of  the  uterus  for  cancer ;  the 
operations  of  Richardson  and  of  Bull  for  removal  of  foreign 
bodies  impacted  in  the  lower  oesophagus ;  Bernays's  operation 


VlU  PREFACE  TO   THE  SECOND  EDITION. 

for  removal  of  growths  in  the  stomach ;  and  the  modifications 
of  Laparo-colotomy  introduced  by  Allingham  and  by  Ball. 

About  forty  new  wood-engravings  have  been  included.  The 
instruments  have  been  mostly  re-drawn  to  scale  from  photo- 
graphs made  on  the  blocks.  Engravings  copied  from  other 
works  have  their  source  uniformly  acknowledged :  engravings 
with  no  name  attached  are  from  drawings  made  by  myself. 

It  only  remains  that  I  should  gratefully  acknowledge  the 
abundant  kindness  of  reviewers  and  friends.  Amongst  the 
latter  I  desire  specially  to  mention  Mr.  L.  M.  Griffiths,  who 
has  generously  and  patiently  done  as  much  in  the  way  of 
proof-reading  for  this  edition  as  he  did  for  the  previous 
one.  Dr.  Thomas  Keith  has  very  kindly  revised  the  descrip- 
tion of  his  mode  of  treating  the  pedicle  in  ovariotomy.  To 
my  pupils,  Messrs.  G.  D.  Edwards,  J.  H.  Fardon,  W.  S. 
Wright,  and  F.  Lace,  I  am  indebted  for  assistance  in  various 
ways. 


Clifton,  Bristol, 

March,  1888. 


PREFACE    TO    THE    FIRST    EDITION. 


The  time  seems  to  have  come  when  it  is  proper  to  gather  together 
and  describe  in  systematic  manner  the  surgical  operations  usuall}- 
spoken  of  as  abdominal.  Of  some  abdominal  operations  it  may 
truly  be  said  that  no  complete  descriptions  have  as  yet  appeared  ; 
others  are  described  only  in  isolated  monographs  in  scattered 
periodicals  ;  while  a  few  appear  only  as  casual  additions  to  large 
works  dealing  with  one  special  disease  or  operation.  This,  I 
believe,  is  the  first  attempt  to  deal  with  the  practical  surgery  of 
the  abdomen  in  one  treatise. 

From  the  descriptive  point  of  view,  the  features  of  abdominal 
surgery,  both  in  grouping  and  in  detail,  lend  themselves  readily 
to  comprehensive  treatment.  Most  of  the  operations  are  per- 
formed for  diseases  which  come,  in  the  first  instance,  within 
the  domain  of  the  physician,  and  the  complete  and  scientific 
accounts  of  these  diseases — their  natural  history,  in  fact — must 
be  looked  for  in  works  on  general  pathology  and  medicine.  In 
their  treatment  by  operation,  the  surgeon  is  associated  with  the 
physician  for  a  definite  practical  purpose ;  which  purpose  involves, 
on  the  part  of  the  surgeon,  not  only  a  general  acquaintance  with 
operative  details,  but  a  special  knowledge  of  tlie  gross  anatomy 
of  the  disease,  and  a  technical  familiarity  with  the  methods  of 
diagnosis. 


X  PREFACE   TO   THE  FIRST  EDITION. 

From  a  practical  point  of  view,  it  is  expedient  that  the 
surgeon,  who  makes  an  abdominal  section  for  a  certain  pre- 
conceived purpose,  should  be  ready  off-hand  to  deal  with  an 
unexpected  contingency.  The  recondite  nature  of  many  ab- 
dominal diseases  frequently  necessitates  conclusions  to  operative 
procedures  very  different  from  what  were  contemplated.  Con- 
fidence and  capacity  on  the  part  of  the  surgeon  who  ventures 
on  abdominal  work  can  scarcely  exist  apart  from  a  complete 
knowledge  of  all  abdominal  operations. 

On  these  principles  this  work  has  been  written  :  to  gather 
together  for  systematic  description  all  abdominal  operations, 
and  to  do  so  after  a  method  which  will  satisfy  the  requirements 
of  the  practical  surgeon.  In  the  selection  of  subjects,  I  have 
followed  popular  habit  rather  than  strict  anatomy.  Thus, 
Hernia  and  Epicystotomy  are  not  included,  though  they  may 
be  considered  as  abdominal  operations.  In  the  choice,  arrange- 
ment, and  balance  of  material,  I  have  steadily  kept  before  me 
the  main  purpose  of  the  work — treatment  by  operation.  The 
anatomy — normal,  of  the  organ  on  which  the  operation  is  to  be 
performed  ;  and  diseased,  of  the  tumour  or  condition  for  which 
operation  is  contemplated — is  chiefly  naked-eye  anatomy ;  that 
is  to  say,  what  concerns  practical  manipulation.  Microscopic 
or  general  pathology,  except  in  so  far  as  it  has  a  direct  bearing 
on  diagnosis  or  treatment,  has  been  excluded.  Symptoms  are 
quoted  with  a  definite  view  to  diagnosis,  rather  than  as  a  part  of 
semeiology.  Statistics  are  provided  only  in  detail  sufficient  to 
give  fair  grounds  for  estimating  the  chances  of  recovery  and  the 
values  of  operations.  Finally,  with  each  operation,  is  given  a 
short  history  of  its  origin  and  advance.  ■  Believing,  as  I  firmly 
do,  that  a  knowledge,  at  first  hand,  of  the  work  of  surgeons  in 


PREFACE   TO   THE  FIRST  EDITION.  xi 

the  past  is  one  of  the  most  valuable  means  of  education  and 
improvement  in  the  present,  I  regret  that  the  space  at  my 
command  prevents  me  from  giving  more  than  a  skeleton  outline 
of  the  historical  material  which  I  have  collected. 

Literary  references  are,  as  far  as  possible,  kept  out  of  the 
text,  and  placed  in  a  separate  list  at  the  end  of  the  book. 
I  am  conscious  that  the  Bibliography  is  very  far  from  being 
complete  :  as  it  represents  roughly  the  amount  of  literature, 
either  in  original  or  in  abstract,  which  I  have  read  in  the 
preparation  of  this  work,  I  trust  that  it  will  be  found  repre- 
sentative. Many  references  in  the  text  are  not  inclnded  in 
the  Bibliography. 

I  have  to  express  my  gratitude  for  obligations.  My  indebted- 
ness to  my  colleagues  on  the  staff  of  the  Bristol  Roj^al  Infirmary 
I  have  partly  expressed  in  the  dedication.  To  many  of  our 
leaders  in  abdominal  surgery — it  is  unnecessary  to  name  them 
— I  am  grateful  for  permission,  always  most  heartily  accorded, 
to  observe  their  work  and  learn  from  their  teaching.  To  my 
friend  Mr.  L.  M.  Griffiths  I  am  indebted  for  much  assistance 
in  the  correction  of  proofs  and  in  the  preparation  of  the  index. 
To  Mr.  J.  W.  Mills  my  thanks  are  due  for  the  translation 
of  monographs  written  in  a  language  with  which  I  am  not 
familiar. 


Ci-iFTON,  Bristol, 
May,  1887. 


TABLE    OF    CONTENTS. 


Section  I. — Diagnosis  of  Abdominal  Tumours 
Topographical  Anatomy  of  the  Abdomen 

Diagnostic  Methods 

Physical  Examination  of  Individual  Organs 
Conditions  Simulating  Abdominal  Tumours 
Diagnostic  Arrangement  of  Abdominal  Tumours 
General  Examination  of  Patient 
Exploratory  Incisions  ..... 


Section  II. — Abdominal  Operations  considkded  Gener 

ALLY        ...        

Nomenclature.     Historical  ..... 

The  Operative  Surgery  of  the  Abdomen    . 
After-treatment  of  Cases  of  Abdominal  Operation    . 


Section    III. — Operations    on    the    Ovaries,    the    Fai 
LOPiAN  Tubes,  and  the  Broad  Ligaments 
Ovariotomy  .... 

Ovarian  Cystoma 
Dermoid  Cysts  of  the  Ovary 
Solid  Growths  of  the  Ovary 
Operations  for  Cysts  in  the  Broad  Ligament  and  Parovarium 
IJemoval  of  the  Uterine  Appendages 

Section  IV. — Operations  on  the  Non-Gravid  Uterus 
Hysterectomy  for  Malignant  Disease         .... 
Hysterectomy  for  Intractable  Inversion    .... 
Hysterectomy  for  Myoma 


Page 
I 

5 

12 

23 

28 
46 

47 


49 
49 

52 


100 
102 
no 
155 
159 
171 

205 
210 
232 
235 


TABLE    OF   CONTENTS.  Xlil 

Section  V. — Operations   on   the  Gravid  Uterus,  and  Page 

FOR  Ectopic  Gestation 268 

Cassarean  Section 273 

Porro's  Operation 285 

Laparo-elytrotomy 291 

Comparative  Survey  of  the  Three  Operations.         .        .        .  297 

Abdominal  Section  for  Rupture  of  the  Uterus.         .         .         .  306 

Operations  for  Ectopic  Gestation 312 

Operation  for  Missed  Labour    .        • 337 

Section  VI. — Operations  on  the  Stomach        ,        .        .  340 

Gastrostomy 345 

Gastrotomy 368 

Gastrorraphy 380 

Operative  Dilatation  of  the  Orifices  of  the  Stomach       .         .  384 

Pylorectomy 389 

Gastro-enterostomy 397 

Duodenostomy 403 

Jejunostomy        ..........  404 

Section  VII. — Operations  on  the  Intestines  .        .        .  406 

Laparotomy  for  Intestinal  Obstruction 414 

Enterotomy 444 

Colotomy             447 

Resection  of  Intestine 470 

Operations  for  Artificial  Anus 490 

Section  VIII. — Operations  on  the  Kidneys     .        .        .  498 

Nephrorraphy ...  505 

Nephro-lithotomy 515 

Puncture  of  the  Kidney 533 

Nephrotomy 541 

Nephrectomy      ..........  551 

Section    IX. — Operations    on    the     Liver    and    Gall- 
bladder         572 

Operations  on  the  Liver    ........  577 

Hepatotomy        .                  .                  583 

Operations  on  the  Gall-bladder 592 

Cholecystotomy          .........  604 

Entero-cholecystotomy      ........  609 

Cholecystectomy ,        .611 


XIV 


TABLE    OF    CONTENTS, 


Section  X. — Operations   on   the   Spleen 
Splenectomy 


Section   XI. — Operations  on  the  Pancreas 
Operation  for  Pancreatic  Cysts 


Page 

.        .  614 

.  616 

.  625 

.  630 

Section    XII. — Unclassified    Operations    ....  633 

Turaours  in  the  Omentum 633 

Tumom's  in  the  Mesentery 636 

Extra-peritoneal  Cysts 638 

Section   XIII. — Supra-pubic   Cystotomy      ....  642 

Section  XIV. — Operations  for  Abdominal  Injuries  and 

Inflammations 695 

Gunshot  wounds           .         .         . 696 

Stab-wounds 715 

Rupture  of  the  Intestine     .         .         .         .         .         .         .         .  719 

Rupture  of  the  Urinary  Bladder 727 

Rupture  of  the  Gall-bladder 734 

Rupture  of  the  Solid  Viscera 735 

Perforating  Appendicitis              73S 

Perforating  Ulcer  of  the  Stomach 747 

Perforating  Typhoid  Ulcer 751 

Purulent  Collections  in  the  Pelvis 756 

Tubercular  Peritonitis 761 

Bibliography 766 

Index 79^ 


LIST    OF    ILLUSTRATIONS. 


No. 
I 
2 

3 
4 
5 
6 

7 

8 

9 

lO 

II 

12 

13 

14 
15 
i6 

17 

i8 

19 
20 
21 
22 

23 
24 

25 

26 

27 
28 

29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
40 


tes     . 
ian  Tumour 


The  regions  of  the  Abdomen  and  their  contents  (Tillaux) 

Diagram  showing  area  of  dulness  in  Asc 

Diagram  showing  area  of  dulness  in  Ovar 

Author's  Reel-holder .... 

Plan  of  Operating-room 

Tait's  catch-forceps    .... 

Wells's  large  pressure-forceps,  bent . 

,,  ,,  ,,  rectangular 

Thornton's  T-shaped  pressure  forceps 
Wells's  large  pressure-forceps,  straight 
Author's  scissors-clamp 
Sponge-holding  forceps 
Keith's  glass  drainage  tube 
Tait's  exhausting  syringe  . 
Koeberle's  glass  drainage-tube 
Author's  suture-instrument 
Wells's  ascites-tube    . 
Nelaton's  cyst-forceps' 
Wells's  clamp-forceps 
Tait's  cyst  trocar 
Wells's  small  cyst  trocar,  Fitch 
Wells's  large  cyst  trocar 
Keith's  cautery-clamp 
Cautery  iron 


Tait's  Staffordshire  knot 
Triple  interlocking  ligature  ;  thr 


s  dome 


ted 


"eads  inser 

,,  ,,  ,,  threads  interlocked 

,,  ,,  ,,  threads  tied 

Diagram  of  Structures  in  Broad  Ligament  (Dorau) 

Vertical  antero-posterior  section  of  uterus  (Courty) 

Relations  of  ureters,  uterine  arteries,  bladder,  &c 

Clover's  crutch 

Uterus  pulled  downwards  by  volsella 

Author's  clamp  for  kolpo-hysterectomy 

Tait's  screw  for  myoma 

Koeberle's  serre-noeud 

Tait's  modification  of  Koeberle'='  serr 

Tait's  temporary  rope  compressor 

Pozzi's  elastic  tourniquet    . 


e-nceud 


Page 
4 
39 
39 
66 
70 
75 
75 
76 

77 
77 
78 
78 
81 
82 
82 

85 
117 
127 
127 
128 
128 
129 
138 
139 
139 
140 
141 
141 
141 
160 
206 
208 
217 
222 
224 

243 
248 
248 
249 
249 


XVI 

No. 

41 
42 

43 

44 
45 
46 

47 
48 

49 
50 
51 
52 
53 
54 
55 
56 
57 
5S 
59 
60 
61 
62 

63 

64 

65 
66 

67 
68 
69 
70 

71 

72 

73 
74 
75 
76 

77 
78 
79 

80 
81 
82 


LIST  OF   ILLUSTRATIONS. 

Keith's  clamp  for  hysterectomy  .... 

Needle  for  carrying  elastic  ligature  through  pedicle 
Closure  of  abdominal  wound  in  hysterectomy  . 
Needle  for  transfixing  pedicle  .... 
Uterus  near  termination  of  first  stage  of  labour 
Placing  of  uterine  sutures  in  Cassarean  Section 
Site  of  fistula  in  Gastrostomy  .... 
Diagram  to  show  Fixation  of  Stomach  in  Gastrostomy 

Eyeless  needle 

Lembert's  suture         .... 

Diagram  of  Intestinal  Anastomosis 

Delepine's  diagram  of  Abdominal  Cavity 

Section  of  dog's  intestine  (Halsted) 

Sectional  drawing  of  parts  concerned  in  Colotomy  (Braune 

Lund's  insufflator        .... 

Lund's  hooks  for  Colotomy 

Lund's  forceps  for  removing  faeces  after  Colotomy 

Makins's  clamp  for  intestinal  resection 

Dupuytren's  intestinal  suture     . 

Appolito's  intestinal  suture 

Lembert's  intestinal  suture 

Czerny's  intestinal  suture  . 

Gussenbauer's  intestinal  suture 

Bishop's  intestinal  suture  . 

Halsted's  plain  quilt-suture 

Diagram  to  show  method  of  intestinal  suture 

Diagrams  showing  varieties  of  artificial  anus 

Structures  in  hilum  of  kidney  (Weisse) 

Anatomy  of  Kidneys 

Pelvis  and  calyces  of  kidney  (Heitzmann) 

Section  showing  relations  of  kidney  to  peritoneum  (Lange) 

Pelvis  of  kidney  and  ureter  exposed  from  behind  (Lange) 

Liver,  Duodenum,  and  Pancreas  (Weisse) 

Hodder's  guarded  aspirating  needle  .... 

Tait's  cholelithotomy  forceps 

Vessels  in  the  hilum  of  the  Spleen  (Weisse) 

Median    Pelvic   Section  of  young   man,  bladder   contracted 

(Langer) 

Median    Pelvic    Section    of  young   man,    bladder    distended 

(Langer) 

Median  Section  of  male  pelvis,  bladder  and  rectum  distended 

(Garson) 

Retractor  for  supra-pubic  cystotomy 


262 
263 
263 
264 
271 
282 
359 
364 
364 
364 
374 
402 
408 
412 
455 
458 
459 
460 
476 
480 
481 
482 
482 
482 
482 
483 

485 
491 
500 
502 
503 
504 
526 

575 
605 
606 
606 
615 

668 

669 

670 
678 


Icbbaminal  Surgtrir. 


Section     I. 


DIAGNOSIS    OF    ABDOMINAL    TUMOURS. 


The  diagnosis  of  tumours  in  the  abdominal  cavity  demands  an 
accurate  comprehension  of  the  topography  of  the  contained 
viscera,  a  practical  acquaintance  with  the  methods  of  physical 
examination,  and  some  knowledge  of  the  nature  of  the  tumours 
which  are  liable  to  be  found  in  connection  with  the  individual 
organs. 

Topographical  Anatomy  of  the  Abdomen. 

For  purposes  of  surgical  diagnosis  we  may  consider  the  whole 
of  the  abdominal  and  pelvic  cavities  as  one.  The  surgical  limits 
of  the  abdomen  are  practically  those  of  the  peritoneum  ;  any- 
thing totally  or  partially  covered  b}'  peritoneum  we  may  here 
reckon  as  abdominal. 

2 


2  DIAGNOSIS   OF  ABDOMINAL    TUMOURS. 

The  abdominal  cavity  is,  roughly  speaking,  a  cylinder,  flatly 
cordate  in  transverse  section,  pointed  or  arched  at  its  extremities. 
The  inward  bulging  of  the  vertebral  column  tends  to  bisect  the 
cylinder  in  its  upper  portion;  in  its  lower  portion  this  bony 
ridge  is  bifurcated  and  carried  outwards  laterally,  as  the 
pelvic  brim.  At  the  top  is  the  diaphragmatic  arch;  at  the 
bottom  is  the  pelvic  cup,  supported  by  the  muscles  in  the 
pelvic  floor. 

The  walls  of  this  cavity  are  chiefly  bony  behind  and  muscular 
in  front.  At  both  extremities  it  is  encased  in  bony  walls,  com- 
pletely behind  and  partially  in  front ;  at  the  upper  end  by  the 
lower  ribs  descending  laterally  and  ascending  in  front,  leaving 
a  V-shaped  gap,  which  is  occupied  by  muscle ;  at  the  lower  end 
by  the  iliac  bones,  which  complete  the  enclosure  behind  and 
laterally,  but  leave  a  muscular  space  between  them  in  front. 
Behind,  the  sacrum  below  and  the  vertebral  column  above, 
measured  by  inches  ;  in  front,  the  pubes  below  and  the  end  of 
the  sternum  above,  each  not  longer  than  one  inch,  complete  the 
bony  portion  of  the  C3'linder. 

Thus  the  outer  muscular  coverings  of  the  abdomen  represent 
a  sort  of  lozenge-shaped  area,  the  four  corners  of  which  lie  at 
the  xiphoid  cartilage,  the  pubes,  the  right  loin  and  the  left  loin, 
in  this  area  all  abdominal  tumours,  if  bulky  enough,  bulge  out- 
wards ;  and  through  this  area  the  diagnosis  and  the  treatment 
of  abdominal  tumours  are  mainly  carried  out.  Through  the 
upper  muscular  boundary  of  the  diaphragm  the  abdomen  can- 
not be  approached ;  but  through  its  lower  boundary  of  the 
pelvic  floor  we  may  derive  important  aids  in  diagnosis,  and 
carry  out  more  than  one  mode  of  treatment. 

It  will  be  seen  that  in  diagnosing  conditions  of  abdominal 
viscera,  we  begin  by  trying  to  eliminate  the  parietes ;  to  ignore, 
or  at  least  to  overcome,  as  far  as  possible,  the  obstacles  which 
they  present  to  examination.  Where  the  abdominal  wall  is 
thinnest  and  most  lax,  in  front,  examination  is  easiest ;  in  the 
loins,  where  the  layers  are  thick  and  tense,  examination  is 
difficult ;  behind  and  under  the  bony  walls,  except  by  special 
methods  in  a  few  cases  of  certain  diseases,  physical  examination 


TOPOGRAPHY.  o 

is  impossible.  The  anatomical  construction  of  the  abdominal 
walls  does  not  here  concern  us  :  this  will  be  considered  when 
speaking  of  treatment. 

For  convenience  of  localising  the  abdominal  organs  the 
surface  has  been  divided  by  four  lines,  two  horizontal  and  two 
vertical,  into  nine  arbitrary  regions.  (Fig.  i.)  The  vertical 
lines  (c.c',  d.d')  extend  from  the  cartilage  of  the  eighth  rib 
to  the  middle  of  Poupart's  ligament.  The  upper  transverse 
line  (a. a')  is  at  the  level  of  the  ninth  costal  cartilage ;  the 
lower  (b.b')  at  the  level  of  the  highest  point  of  the  crest  of  the 
ilium.  The  upper  and  lower  limits  are  at  the  diaphragm  and 
pelvis.  The  middle  regions  are  named,  from  above  downwards, 
the  Epigastric,  the  Umbilical,  and  the  Hypogastric.  The 
lateral  regions,  from  above  downwards,  are  named  respectively 
right  or  left  Hypochondriac,  Lumbar,  and  Iliac. 

The  contents  of  these  regions  are,  according  to  Tillaux : 

Epigastric  (I.) — From  before  backwards  we  find  in  the 
Epigastrium,  the  left  lobe  of  the  liver,  a  part  of  the  anterior 
surface  of  the  stomach  with  its  cardiac  and  pyloric  orfices,  the 
gastro-hepatic  omentum,  and  the  foramen  of  Winslow.  In  the 
anterior  edge  of  the  foramen  we  find :  the  hepatic  artery  in 
front ;  the  hepatic  and  cystic  ducts,  and  the  origin  of  the  ductus 
choledochus,  in  the  middle;  the  portal  vein  behind  the  branches 
of  the  great  sympathetic,  and  the  end  of  the  right  vagus. 
Behind  the  stomach  we  have  the  second  and  third  portions  of 
the  duodenum,  the  pancreas,  the  cceliac  axis  and  its  branches, 
the  superior  mesenteric  artery  surrounded  by  lymphatic  glands, 
and  the  solar  plexus ;  and  behind  all,  the  aorta  and  vena  cava, 
resting  on  the  vertebral  column. 

Right  Hypochondriac  (II.) — Chiefly  occupied  by  the  right 
lobe  of  the  liver.  Behind  it  lie  the  gall-bladder,  a  small  portion 
of  the  transverse  colon,  the  upper  end  of  the  right  kidney  and 
its  supra-renal  body. 

Left  Hypochondriac  (HI.) — Mainly  occupied  by  the  large 
cardiac  portion  of  the  stomach,  and  the  spleen  with  the  gastro- 
splenic  omentum ;  contains  also  the  upper  end  of  the  left 
kidney,  the  left  supra-renal,  a  portion  of  the  descending  colon, 

2  * 


Fig.   I.  (after  TillauxJ. 

Showing  the  Regions  of  the  Abdomen  and  their  Contents. 


I.  Epigastric.  II.  Right  Hypochondriac.  III.  Left  Hypocliondriac.  IV.  Umbilical. 
V.  Right  Lumbar.    VI.  Left  Lumbar.    VII.  Hypogastric.     VIII.  Right  Iliac.     IX.  Left  Iliac. 

I.  Diaphragm.  2.  Liver.  3.  Pylorus.  4.  Gall-bladder.  5.  Duodenum.  6.  Right  Kidney. 
7.  Small  Bowel.  8.  Ascending  Colon.  9.  Iliac  Crest.  10.  Cacum.  n.  Appendix  Vermiformis. 
12,  18.  Obturator  Vessels,  R.  &  L.  13,  17.  Obturator  Membrane.  14  16.  Corpora  Cavernosa. 
15.  Urethra.  19.  Bladder.  20,  22.  Rectum,  Sigmoid  Flexure  (should  be  ^  shaped).  21.  Left 
Ilium.  23,  24.  Iliac  Vessels.  25.  Descending  Colon.  26.  Vena  Cava  inf.  27.  Aorta.  28.  Lelt 
Kidney.  29.  Transverse  Colon.  30.  Greater  Curvature  of  Stomach.  31.  Spleen.  32.  Cardiac 
Orifice  oi  Stomach.     33.  Pancreas. 


DIAGNOSTIC    METHODS.  » 

and  the  tail  of  the  pancreas.  Sometimes  the  left  lobe  of  the 
liver  extends  into  this  region. 

Umbilical  (IV.) — The  great  omentum,  the  transverse  colon, 
the  bulk  of  the  small  intestine,  the  mesenter}/,  the  aorta,  and 
the  inferior  vena  cava. 

Lumbar  regions,  right  and  left  (V.  and  VI.) — Some  convolu- 
tions of  the  small  intestine ;  the  colons,  ascending  on  the  right, 
descending  on  the  left ;  the  kidne5'S  and  ureters,  and  masses  of 
cellulo-adipose  tissue. 

Hypogastric  (VII.) — The  great  omentum,  the  small  intestine, 
the  bladder  when  distended,  and  the  uterus  when  enlarged. 

Iliac,  right  and  left  (VIII.  and  IX.)— On  the  right,  the 
caecum ;  on  the  left,  the  sigmoid  flexure,  covered  by  convolutions 
of  the  small  intestine. 

Tumours  first  appear  in  the  situation  of  the  organs  from 
which  they  grow,  and  their  main  attachments  are  the  same. 
Even  if  they  encroach  upon  other  regions,  as  they  very  frequently 
do,  abdominal  tumours  usually  have  their  chief  bulk  in  the 
normal  situation  of  the  organs  from  which  they  spring.  These 
facts  are  of  supreme  importance  in  diagnosis. 


Diagnostic  Methods. 

Certain  methods  of  examination  of  the  abdomen  in  a  patient 
suspected  of  abdominal  disease  are  followed.  They  are : 
Inspection  ;  Palpation  through  parietes,  vagina,  and  rectum  ; 
Percussion  ;  Auscultation  ;  Exploratory  Puncture. 

Inspection. — If  the  patient  is  in  bed,  we  note  the  position 
naturally  assumed.  We  note  any  lack  of  freedom  in  movement, 
as  in  raising  the  head,  in  turning,  or  in  drawing  up  the  limbs. 
Any  inflammation  in  the  abdomen  is  inconsistent  with  free 
movement.  If  the  patient  lies  very  still,  with  the  knees  drawn 
up,  we  may  suspect  peritonitis.  If,  while  there  is  much  pain, 
the  patient  moves  restlessly  about,  perhaps  rolling  on  his  face 


6  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

or  assuming  the  genu-pectoral  position,  we  may  suspect  colic 
or  some  form  of  acute  intestinal  strangulation. 

The  abdominal  walls  are  inspected  while  the  patient  lies 
comfortably  in  the  supine  position.  We  note  the  size  of  the 
abdomen  generally,  and  whether  its  bulk  and  symmetr}^  are  in 
proportion  with  those  of  the  chest.  We  mark  any  irregularities 
on  its  surface,  particularly  observing  the  localities  in  which  they 
are  placed.  Uniform  swelling  is  observed  to  be  flat,  globular, 
diffuse,  or  circumscribed.  The  appearance  of  a  bulky  abdomen 
with  a  lean  chest  contrasts  with  a  depressed  and  shrunken 
abdomen  in  cases  where  the  chest  appears  of  normal  develop- 
ment. We  further  note  ever}'  peculiarity  in  the  parietes  :  their 
fatness  or  leanness ;  whether  they  are  white  and  glossy,  or  red 
and  dull;  whether  the  skin  is  distended  with  cedema,  or  shrivelled 
and  puckered ;  whether  the  veins  are  dilated  or  not ;  and,  in 
fact,  everything  which  can  be  interpreted  as  being  in  the 
slightest  degree  abnormal. 

The  movements  of  the  abdomen  are  watched — first  during 
eas}^  respiration,  and  then  during  deep  respiration.  The  ab- 
dominal walls  may  move  readily  and  freely,  or  they  may  remain 
fixed  while  the  chest  moves.  An}^  conspicuous  point,  as  the 
umbilicus,  may  sometimes  be  seen  to  glide  up  and  down  over  a 
growth,  or  the  growth  itself  may  visibly  move  upwards  and 
downwards  with  each  act  of  expiration  and  inspiration. 

Palpation. — For  palpation  of  the  abdomen  the  patient  is 
placed  supine  in  bed,  with  the  knees  drawn  up  and  the  head 
slightly  elevated,  to  give  relaxation  of  the  abdominal  muscles. 
Too  much  flexion  of  the  spine,  while  giving  greater  relaxation  of 
the  abdominal  walls,  defeats  the  object  of  palpation  by  deepen- 
ing the  antero-posterior  measurement  and  crowding  the  contents 
forwards.  A  thin  abdomen,  or  one  relaxed  by  repeated  preg- 
nancies, is  more  easily  examined  than  a  fat  abdomen  or  one  of  a 
woman  who  has  never  borne  children,  A  stout  muscular  man 
presents  the  abdomen  most  difficult  to  examine  by  palpation. 

While  palpation  is  being  performed  the  attention  of  the 
patient  is  diverted  by  questions  about  the  symptoms  and  so 


DIAGNOSTIC  METHODS.  7 

forth,  which  will  ensure  a  natural  condition  of  the  abdominal 
walls.  Any  special  instructions,  as,  to  breathe  deeply  or  to 
count,  have  a  tendency  to  call  attention  to  the  process  of 
examination  rather  than  to  divert  attention  therefrom. 

The  palm  of  the  hand,  which  must  not  be  cold,  and  which 
is  said  to  be  made  more  sensitive  by  being  dipped  in  hot  water, 
is  laid  flatly  on  the  abdomen  and  pressed  steadily  and  firml}', 
but  not  roughly,  downwards.  When  it  is  depressed  as  far  as 
possible,  if  no  tumour  prevents  it,  the  hand  is  rotated  outwards, 
and  its  outer  margin  and  fingers  may  be  pushed  deeper,  so  as, 
without  much  discomfort,  to  reach  the  spine  and  perhaps  the 
brim  of  the  pelvis.  The  pressure  being  steadily  maintained, 
the  hand,  and  the  abdominal  wall  with  it,  is  moved  hither  and 
thither  over  the  abdominal  contents.  The  hand  is  not  to  be 
moved  over  the  parietes,  but  the  parietes  and  hand  together  are 
to  be  moved  over  the  abdominal  organs.  Without  raising  it, 
the  hand  is  slid  on  to  another  area,  and  the  process  repeated  till 
the  whole  abdomen  has  been  explored. 

By  this  means  we  shall  make  out  any  small  or  deeply-placed 
tumour,  such  as  cancer  of  the  pylorus  or  pancreas ;  floating 
kidney;  abdominal  aneurism;  mesenteric,  omental  or  peritoneal 
growths  ;  and  small  tumours  of  the  ovary  that  may  have  escaped 
from  the  true  pelvis.  In  this  way  also  we  shall  be  able  to  detect 
any  undue  degree  of  spasm  or  tension  of  the  abdominal  muscles, 
pointing  to  underlying  irritation  or  inflammation.  We  enquire 
into,  and  observe  the  expression  of,  the  sensations  of  the  patient 
while  being  examined.  In  some  cases,  usually  of  colic,  pressure 
affords" relief.  In  others,  pain,  in  all  degrees  from  the  slightest 
to  the  most  severe,  may  be  caused  by  pressure.  In  every  case 
it  is  important  to  discriminate  between  the  h3'per?esthesia  of 
the  nervous  or  hysterical  patient  and  the  genuine  tenderness 
begotten  of  inflammation.  In  inflammation  the  pain  is  usually 
limited  to  the  inflamed  area ;  in  simple  hyperaesthesia  the  pain 
radiates  in  various  directions  over  the  skin  of  the  chest,  thighs, 
or  back. 

If  a  tumour  is  visible,  we  seek  by  palpation  to  elucidate  as 
many  of  its  characters   as   possible.     Is   it    circumscribed   or 


8  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

diflfuse  ?  Is  it  solid  or  fluid  ?  Is  it  fixed  or  movable  ?  In  the 
case  of  a  circumscribed  tumour  that  is  not  very  large,  the  hand 
can  be  partly  insinuated  between  it  and  the  resisting  bony 
boundaries.  The  feel  of  a  solid  growth  is  characteristic :  be- 
tween a  semi-solid  or  boggy  growth  and  one  distinctlj'  fluid 
there  are  many  grades  difficult  of  recognition.  We  seek  to 
detect  the  condition  by  trying  to  elicit  the  sign  of  fluctuation. 
While  the  fingers  or  the  palm  of  one  hand  lie  firmly  pressed  on 
one  side  of  the  growth,  the  fingers  of  the  other  tap  it  on  the 
opposite  side ;  if  the  swelling  is  fluid,  we  feel  a  thrill  or  series  of 
vibratory  thrills.  The  fluctuation  thrill  may  not  be  detected  in 
fluid  tumours  if  their  cyst  walls  are  thick  and  tense,  or  if  the 
fluid  is  thick  or  contained  in  many  cysts.  To  detect  mobility, 
the  hand  is  laid  flatly  on  successive  aspects  of  the  tumour,  and 
endeavours  to  move  it  in  various  directions  ;  or  the  tumour 
may  be  grasped  bodily  between  the  hands,  and  movement 
given  to  it. 

By  palpation  also  we  seek  to  make  out  any  irregularities  on 
the  surface  of  the  growth,  or  any  localised  differences  of  consist- 
ence in  its  mass.  The  fingers  will  note  any  sensation  of  grating 
or  fremitus  on  its  surface  indicating  peritonitis,  or  they  may  feel 
that  the  parietal  peritoneum  glides  readily  over  the  tumour. 

New  facts  may  be  discovered  by  turning  the  patient,  first  on 
one  side  and  then  on  the  other.  These  relate  chiefl}^  to  mo- 
bility, the  extent  and  direction  of  it,  or  its  non-existence ;  but 
these  characters  are,  perhaps,  better  ascertained  by  the  pal- 
pating hand  than  by  change  of  position. 

Palpation  by  vagina  in  all  abdominal  tumours  not  high  up, 
and  not  small,  is  of  great  diagnostic  value.  By  this  plan  we 
may  be  able,  not  only  to  elicit  important  facts  as  to  the  physical 
character  of  the  tumour,  but  also  to  make  out  its  connection  or 
non-connection  with  the  uterus.  Not  infrequently  the  tumour 
may  be  poised  between  the  finger  in  the  vagina  and  the  hand  on 
the  abdominal  wall,  and  the  situation  and  attachments  of  its 
pedicle  or  base  made  out.  Very  often  a  tumour  which,  through 
the  abdominal  walls,  gives  the  characters  of  a  single  cyst,  is 
found  through  the  vagina  to  have  its  lower  portion  composed  of 


\ 


DIAGNOSTIC   METHODS.  ^ 

several  cysts,  and,  frequently,  of  solid  material  as  well.  The 
use  of  the  uterine  sound  is  an  aid  to  vaginal  palpation.  By 
means  of  it  we  can  ascertain  with  accuracy  the  length  of  the 
uterine  cavity,  the  extent  and  range  of  mobility  of  the  fundus^ 
and  the  situation  of  the  whole  organ  generally  with  reference  to- 
the  growth.  In  not  a  few  cases  the  uterus  lies  immediately 
behind  the  pubes,  and  its  fundus  can  be  readily  palpated 
through  the  abdominal  wall ;  while  the  whole  organ  may  be 
moved  between  the  fingers,  outside  on  fundus  and  inside  on 
cervix.  Often,  again,  it  is  pressed  downwards  and  retroverted,. 
and  its  outlines  can  be  made  out  in  Douglas's  pouch.  The 
middle  finger  in  the  rectum,  with  the  forefinger  in  the  vagina,, 
the  perineum  between  them  being  pushed  upwards,  will  give 
more  information  usually  than  the  simple  finger  in  the  vagina  ; 
but  this  plan  is  not  always  agreeable  to  the  patient. 

Palpation  by  the  rectum  may  be  carried  out  in  the  manner  just 
mentioned,  or  by  the  finger  in  the  rectum  alone,  or  by  the  whole 
hand  introduced  while  the  patient  is  anaesthetised.  Very  rarely 
indeed  can  the  last  method,  in  itself  an  operation  of  some 
severity,  be  considered  advisable.  Only  in  certain  cases  of 
extreme  difficult}^,  in  which  it  is  of  vital  importance  that  opera- 
tion, even  exploratory,  should  not  be  undertaken  till  diagnosis  is 
certain,  is  it  admissible.  The  results,  it  is  very  generally 
admitted,  of  manual  exploration  through  the  rectum  are  often 
disappointing.  Few  surgeons,  even  among  those  of  the  largest 
experience,  have  had  recourse  to  this  method  of  diagnosis. 

Percussion. — Percussion  of  the  abdomen  is  performed  while 
the  patient  is  in  the  same  position  as  for  palpation — that  is,  in 
the  supine  posture  with  knees  drawn  up.  But  change  of  posi- 
tion, first  to  one  side  and  then  to  the  other,  though  but  slightly 
adding  to  the  value  of  palpation,  introduces  important  aids  to 
diagnosis  by  percussion.  The  practice  is  best  carried  out  by 
tapping  the  fingers  of  the  left  hand,  placed  on  the  abdomen^ 
with  the  fingers  of  the  right  hand.  If  a  wide  area  is  to  be 
percussed,  it  is  a  good  plan  to  percuss  b}'  successive  taps  on  one 
finger   after    another  while  they  are   spread  out    as   much   as 


10  DIAGNOSIS  OF  ABDOMINAL   TUMOURS. 

possible  over  the  abdomen.  If  the  wrist  and  fingers  are  kept 
stiff,  and  pressure  is  made  with  the  arm,  more  uniform  force  is 
exerted,  and  more  exact  comparison  is  possible  than  if  only  one 
finger  is  used,  and  moved  from  one  spot  to  another.  Some 
prefer  always  to  use  a  pleximeter. 

It  is  of  great  importance  to  bear  in  mind  the  different  values 
of  deep  and  of  superficial  percussion.  A  "  minimised  note," 
produced  by  gentle  taps,  will  reveal  increased  dulness  in  small 
or  thin  solid  bodies,  which  would  not  be  detected  by  strong 
percussion.  A  thickened  omentum,  or  pelvic  cellulitis  extend- 
ing up  into  the  abdominal  parietes,  or  a  small  growth  lying 
over  the  intestines,  would  be  revealed  in  this  way.  Deep  per- 
cussion, again,  may  reveal  dulness  from  a  growth  covered  by 
intestines,  which  would  give  a  resonant  note  to  superficial 
percussion.  In  those  parts  where  the  abdominal  walls  are 
thick,  as  in  the  loins,  slight  percussion  is  useless,  as  it  reveals 
only  the  dulness  caused  by  the  thick  muscles. 

In  examining  the  whole  abdomen,  particular  attention  is  to 
be  paid  to  the  umbilical,  the  epigastric,  and  the  lumbar  regions. 
Free  fluid  in  the  peritoneal  cavity,  always  gravitating  to  the 
lowest  part,  is  first  detected  by  percussion  in  the  lumbar 
regions.  Circumscribed  and  movable  growths  have  a  tendency 
to  rise  above  the  intestines  to  the  surface.  It  must  be  remem- 
bered that  a  dull  note  in  the  flanks  may  be  caused  by  fluid 
faeces  in  the  intestines  ;  and  further,  that  this  dulness  may  be 
changed  to  resonance  by  turning  the  patient  on  one  side,  and 
so  causing  the  fluid-laden  intestines  to  gravitate  downwards. 
Again,  a  colon  distended  with  gas  may  cause  resonance  in  the 
loin  even  when  ascites  is  present.  When  only  a  small  amount 
of  fluid  lies  in  the  abdominal  cavity,  the  mesentery  is  long 
■enough  to  permit  the  gas-containing  intestines  to  float  to  the 
surface,  thus  giving  a  resonant  note. 

In  the  case  of  a  tumour  being  visibly  and  palpably  present, 
percussion  is  chiefly  valuable  as  eliciting  the  position  of  reso- 
nant intestine.  Sometimes  the  tumour  is  all  gas-containing 
intestine — meteorism  or  phantom  tumour.  Occasionally  tracts 
of  resonance  passing  over   a   growth  indicate  the  presence  of 


DIAGNOSTIC  METHODS.  11 

adherent  bowel.  But  in  the  great  majority  of  cases  percussion 
is  of  value  chiefly  as  demonstrating  the  "tympanic  corona"  (as 
Tait  well  names  it),  which  surrounds  a  growth  overl3dng  intes- 
tine, in  contrast  with  the  circular,  semi-circuiar,  or  crescentic 
area  of  resonance  which  is  found  in  cases  of  peritoneal  dropsy. 
In  diagnosing  ascitic  fluid  from  C3'sts,  in  detecting  slight 
enlargements  of  liver  and  spleen,  and  in  demonstrating  the 
presence  of  gas  in  a  swelling,  percussion  is  of  great  value  :  in 
all  other  respects,  as  a  diagnostic  method,  it  is  much  inferior  to 
palpation  skilfully  practised. 

Auscultation. — As  a  method  of  phj^sical  diagnosis  applied  to 
the  abdomen,  auscultation  has  not  as  yet  been  very  fruitful  of 
results.  Vascular  bruits  in  aneurisms,  and  in  fibroid  or  sarco- 
matous tumours,  friction-sounds  in  peritonitis,  and  the  sounds 
of  the  fcetal  and  the  placental  circulation,  are  the  most  im- 
portant revelations  of  the  auscultatory  method.  There  are 
signs  that  the  use  of  the  stethoscope  in  differentiating  intestinal 
sounds  may  be  of  clinical  value.  Such  sounds,  produced  by 
the  mingling  of  fluid  and  gas  during  intestinal  movement,  and 
described  as  metallic,  gurgling  or  splashing,  may  be  heard 
during  health,  and,  no  doubt,  in  modified  manner  during  disease. 
But  clinical  data  as  to  the  character  of  these  sounds  are  not  yet 
definite  enough  to  be  of  practical  use.  In  certain  cases  of  dila- 
tation of  the  stomach,  in  cholera  and  diarrhoea,  augmentation 
or  perversion  of  these  sounds  can  be  detected.  In  intestinal 
obstruction,  any  such  addition  to  our  powers  of  diagnosis  would 
be  heartily  welcomed  ;  but  as  yet  no  very  definite  clinical  facts 
have  been  established  by  auscultation. 

Exploratory  Puncture. — Removal  of  a  small  portion  of  the 
contents  of  an  abdominal  tumour  by  a  hollow  needle  attached 
to  an  exhausting  syringe,  is  a  method  of  diagnosis  of  somewhat 
imcertain  value.  In  many  cases  it  is  useless;  in  others  it  makes 
a  diagnosis  which  does  not  modify  the  treatment ;  in  a  few 
cases  it  is  of  real  and  decided  benefit.  There  can  be  no  doubt 
that  the  method  has    been  employed   with   undue   frequency. 


12  DIAGNOSIS   OF  ABDOMINAL    TUMOURS. 

having  been  adopted  to  solve  difficulties  which  ought  by  other 
means  to  have  been  overcome.  Furthermore,  it  is  sometimes 
attended  with  danger,  and  has  even  caused  death.  Perhaps 
the  best  criterion  of  the  value  of  exploratory  puncture  is  the 
fact  that  it  is  very  rarely  used  by  our  most  skilled  and  expe- 
rienced operators. 

If  it  is  decided  to  employ  the  exploring  needle,  particular 
care  must  be  taken  to  see  that  the  instrument  is  purified  by 
repeated  washings  with  antiseptic  lotions.  The  skin  at  the  site 
of  puncture  must  also  be  purified  ;  for  a  group  of  epidermic 
scales,  or  even  a  small  piece  of  skin,  may  be  carried  along  by 
the  point  of  the  needle  and  cause  sepsis.  Not  a  few  cysts  have 
undergone  septic  suppuration  as  a  result  of  the  introduction  of 
the  exploring  trocar  ;  therefore  every  possible  precaution  ought 
to  be  taken  to  avoid  such  a  catastrophe. 


Physical  Examination  of  the  Individual  Organs. 

THE    LIVER. 

Palpation. — In  health,  all  of  the  liver  that  can  be  felt  is  its 
lower  margin  where  it  lies  below  the  ribs,  and  a  portion  of  the 
anterior  surface  of  the  left  lobe  in  the  epigastrium.  In  men,  it 
may  be  impossible  to  palpate  the  liver  at  all,  or  it  may  simply 
be  detected  as  a  line  of  increased  resistance.  In  women,  and 
particularly  in  those  who  have  lax  parietes  from  child-bearing,, 
the  hepatic  margin  can  usually  be  distinctly  felt  and  traced. 
While  the  fingers  examine  the  condition  of  the  portion  of  liver 
within  reach,  we  take  cognizance  of  the  freedom  with  which 
the  organ  moves  during  the  acts  of  respiration.  We  note  also 
any  complaints  of  pain  or  tenderness  during  palpation.  When 
the  liver  is  enlarged  it  descends  within  easy  reach,  and  its 
surface  is  carefully  examined  for  abnormalities.  Hardness,  or 
bogginess,  or  fluctuation  ;  irregularities  of  surface — their  size 
and  consistence ;  and  the  general  form  of  the  enlargement,  are 
the  points  to  be  mainl}'  attended  to.     Hepatic    fremitus  from 


EXAMINATION   OF  ORGANS.  13 

peri-hepatitis  and  hj^datid  fremitus  may  be  felt  by  the  hand.  A 
distended  gall-bladder  may  sometimes  be  felt  in  health  ;  and 
Guttmann*  says  that  by  squeezing  it  he  has  caused  its  contents 
to  escape  through  the  excretory  ducts.  In  pathological  enlarge- 
ment the  gall-bladder  is  readily  felt  extending  below  the  liver 
margin. 

Percussion. — On  account  of  the  overlapping  of  the  lung,  the 
upper  limits  of  the  liver  cannot  be  accuratel}^  determined  by 
percussion.  Between  the  highest  part  of  liver  and  the  thoracic 
wall  there  is  such  a  depth  of  lung  that  a  clear  resonant  note  is 
given  ;  and  for  a  little  distance  lower,  only  relative  dulness  or 
flatness  is  obtained.  Absolute  hepatic  dulness  is  elicited  where 
the  liver  is  in  close  contact  with  the  thoracic  wall,  or,  at  least, 
not  separated  from  it  by  air-containing  lung.  As  relative  dul- 
ness is  very  variable  over  the  hepatic  region,  we  use  the  sign  of 
absolute  dulness  to  define  its  limits.  Percussion  is  performed 
during  the  respiratory  pause,  and  along  the  four  lines — sternal, 
para-sternal,  mammillary,  and  axillary.  For  defining  its  upper 
limits:  in  the  mid-sternal  line  dulness  is  obtained  at  the  base 
of  the  xiphoid  process;  in  the  para-sternal  line,  just  above  the 
sixth  rib ;  in  the  mammillary  line,  at  the  lower  border  of  the 
sixth  rib  ;  and  in  the  axillary  line  it  is  found  at  the  level  of  the 
eighth  rib.  Behind,  hepatic  dulness  is  found  as  high  as  the 
tenth  rib.  The  lower  limits  of  hepatic  dulness  are  as  follows  : 
in  the  mid-sternal  line,  half-way  between  the  base  of  the  xiphoid 
process  and  the  umbilicus ;  in  the  para-sternal  and  mammillary 
lines,  it  coincides  with  the  free  margin  of  the  ribs  ;  in  the  axil- 
lary line,  between  the  tenth  and  eleventh  ribs ;  behind  this, 
hepatic  dulness  is  lost  in  that  caused  by  the  thick  muscles  of 
the  back.  In  women,  the  liver  dulness  may  extend  from  half 
an  inch  to  an  inch  lower.  In  percussing  the  lower  portions  of 
the  liver,  a  minimised  note  is  necessary  to  produce  absolute 
dulness,  on  account  of  its  being  thinner  and  lying  over  ■  air- 
containing  viscera. 

As  the  patient  lies  supine,  the  liver  rotates  a  little  on  its 
transverse  axis,  and  the  anterior  margin  slips  up  under  the  ribs, 
*  Handbook  of  Physical  Diagnosis,  New  Syd.  Soc.,  1879, 


14  DIAGNOSIS  OF  ABDOMINAL   TUMOURS. 

elevating  the  lower  limit  of  anterior  dulness.  The  erect  posture 
corrects  this.  The  liver  may  be  dragged  up  by  contraction  of 
lungs  or  pleura,  or  pushed  up  by  growths  distending  the  ab- 
dominal cavity.  In  certain  diseases  it  becomes  enlarged,  often 
to  enormous  size,  and  in  such  case  the  increase  is  downwards, 
occupying  part  or  the  whole  of  the  anterior  abdomen.  In  such 
enlargements  percussion  will  always  demonstrate  continuity  in 
the  dulness  found  over  the  hepatic  area.  A  healthy  gall-bladder 
cannot  be  detected  by  percussion :  in  disease,  a  dull  note  is 
given  over  the  area  of  its  increase. 

Auscultation  is  of  little  value  as  a  mode  of  examining  the 
liver.     A  friction-sound  may  be  heard  in  peri-hepatitis. 

Explovatovy  puncture  has  been  frequently  employed  in  diag- 
nosing diseases  of  the  liver.  It  is  chiefly  valuable  in  detecting 
the  nature  of  fluid  in  cystic  or  suppurative  enlargements : 
it  also  helps,  in  doubtful  cases,  in  diagnosing  whether  the 
enlargement  is  solid  or  fluid.  Rarely  a  small  piece  of  tissue 
removed  by  the  needle,  and  examined  by  the  microscope,  has 
revealed  the  nature  of  a  new  growth.  The  procedure  is  not 
free  from  danarer,  remote  as  well  as  immediate. 


THE    KIDNEYS. 

Palpation. — A  kidney  that  lies  in  its  proper  position,  and  is 
not  enlarged,  is,  as  a  rule,  beyond  the  reach  of  palpation.  In 
thin  subjects,  with  lax  abdominal  walls,  the  normal  kidney  may 
sometimes  be  felt.  Between  the  fingers  of  one  hand  pressed 
deeply  in  the  costo-iliac  space  behind,  and  the  opposed  fingers 
of  the  other  hand  in  front,  the  lower  third  or  so  of  the  kidney 
may  be  palpated  ;  or  with  one  hand,  the  thumb  being  in  front 
and  the  fingers  behind,  the  loin  may  be  firmly  grasped  and  the 
kidney  felt  through  the  muscles.  Size  can  be  estimated  more 
accurately  by  the  grasp  of  one  hand  than  between  two  hands  : 
for  detecting  slight  enlargements,  palpation  between  thumb  and 
fingers  of  one  hand  is  perhaps  the  better  method.  If  the 
patient  lie  over  a  pillow  on  the  side  opposite  that  being  ex- 
amined,   the   costo-iliac    space   is   enlarged,    and   more   of  the 


EXAMINATION   OF  ORGANS.  15- 

kidney  is  exposed  to  palpation  ;  but  the  advantage  so  gained 
is  partly  counterbalanced  by  the  increased  tension  of  the  loin 
muscles.  All  of  the  healthy  kidney  that  can  be  felt  is  the 
lower  third  or  thereabouts  of  its  posterior  border,  and  a  little 
portion  of  its  lower  anterior  surface ;  the  rest  is  merely  a 
sensation  of  something  grasped  with  a  consistency  like  that  of 
kidney. 

If  the  kidney  is  readily  felt,  we  may  conclude  that  it  is 
enlarged.  A  kidney  increasing  in  size  cannot  extend  far  up- 
wards, and  not  at  all  backwards,  on  account  of  the  lumbar 
muscles  :  it  grows  downwards  and  forwards — that  is,  more  and 
more  within  the  reach  of  the  palpating  fingers.  In  diagnosing 
displacements  and  undue  mobility  of  the  kidney,  palpation  is  of 
great  value.  Tenderness  on  pressure,  in  renal  as  in  other  in- 
flammations, is  a  sign  of  importance  elicited  by  palpation. 
Fluctuation  or  solidity,  with  various  degrees  of  hardness  or 
softness,  are  all  signs  of  diagnostic  value.  The  grating  of 
stones  in  a  kidney  has  been  felt  through  the  abdominal  walls. 
In  cases  of  great  enlargement,  the  colon  may  be  felt  passing 
over  the  surface  of  the  tumour. 

Percussion. — The  kidney,  being  in  close  relation  with  solid 
bodies, — liver  on  one  side,  spleen  on  the  other,  lumbar  muscles 
and  vertebrae  behind,  while  it  is  embedded  in  a  thick  capsule  of 
fat, — cannot  be  mapped  out  by  percussion.  The  absence  of 
kidney  from  one  side  may,  in  lean  subjects,  give  a  note  on 
percussion  less  dull  than  on  the  other  side  where  it  is  present. 
If  there  is  renal  enlargement,  a  resonant  area  in  the  loin 
is  encroached  upon  and  replaced  towards  the  front  by  an 
area  of  dulness.  At  the  inner  margin  of  the  kidney,  extra 
resonance  may  be  obtained  from  the  colon  distended  by 
gas.  In  considerable  enlargement,  a  resonant  area  from  a 
distended  colon  may  longitudinally  traverse  the  surface  of  the 
kidney. 

Exploratory  puncture  is  used  in  the  diagnosis  of  renal  tumours* 
It  will  tell  whether  an  enlargement  is  solid  or  fluid ;  and  if 
fluid,  it  will  tell  the  nature  of  it — whether  suppurative,  cystic,, 
hydronephrotic,  or  hydatid.     As  puncture  by  trocar  can,  in  fluid 


16  DIAGNOSIS  OF  ABDOMINAL   TUMOURS. 

enlargements  of  the  kidney,  more  often  than  of  other  abdominal 
organs,  be  continued  beyond  the  purpose  of  diagnosis  into  a 
plan  of  treatment,  its  employment  is  most  legitimate  in  kidney 
diseases. 

THE    SPLEEN. 

Palpation. — The  healthy  spleen  is  usually  be5^ond  the  range 
-of  touch.  In  favourable  circumstances,  however,  as  in  thin 
subjects  with  lax  muscles,  and  during  deep  inspiration  in  the 
erect  posture,  the  fingers  insinuated  below  the  margins  of  the 
ribs  may  feel  the  organ.  By  this  plan  slight  enlargements  are 
best  detected.  As  the  spleen  enlarges,  it  appears  at  the  costal 
margin  below  the  site  of  the  apex  beat,  and  continues  to  in- 
crease downwards  and  forwards.  It  lies,  when  enlarged,  imme- 
diately under  the  parietes  over  the  intestines,  and  can  readily 
be  palpated.  The  characteristic  sensation  imparted  by  splenic 
substance,  and  its  rounded  inner  margin  indented  with  one  deep 
notch  and  one  or  more  others  less  deep,  render  the  diagnosis  of 
spleen  by  palpation  comparatively  easy.  Its  rounded  posterior 
margin,  if  it  do  not  lie  behind  the  border  of  the  quadratus 
lumborum,  may  sometimes  he  differentiated.  The  spleen, 
even  when  greatly  enlarged,  is  usually  movable  in  lateral 
direction. 

Percussion. — The  spleen,  as  it  lies  over  air-containing  organs, 
must  be  percussed  gently.  Differences  in  the  area  of  dulness 
may  be  elicited  as  the  patient  lies  on  the  back  or  the  side,  as  he 
stands  up,  and  as  he  forcibly  expires  or  inspires;  In  the  erect 
posture,  the  spleen  descends  ;  as  the  patient  lies  on  the  right 
side,  it  gravitates  away  from  the  surface ;  in  expiration  the  lung 
ascends  from  it,  and  increases  its  area  of  dulness ;  in  inspiration 
the  reverse  takes  place,  a  forced  inspiration  sometimes  causing 
the  splenic  dulness  completely  to  disappear.  The  upper  third 
of  the  spleen  cannot  be  recognised  by  percussion.  Generally 
speaking,  the  splenic  dulness  in  its  most  marked  condition  with 
the  patient  erect,  and  in  the  pause  after  expiration,  is  repre- 
sented by  an  oval  patch  lying  midway  between  the  scapular 
and  axillary  lines,  and  bounded  above  by  the  upper  border  of 


EXAMINATION  OF  ORGANS.  17 

the  ninth  rib,  and  below  b)'  the  lower  border  of  the  eleventh 
rib.  The  healthy  spleen  may  be  pushed  downwards  by  any 
pathological  increase  in  the  size  of  the  left  pleural  cavity :  it 
ma)'  be  pushed  upwards  by  ascites,  tympanites,  or  any  growth 
filling  the  abdominal  cavity.  It  is  usually  indistinguishable  by 
percussion  from  any  non- resonant  tumour  or  collection  of  fluid 
which  displaces  it. 

Auscultation. — A  vascular  bruit  is  sometimes  to  be  heard  over 
an  enlarged  spleen.  If  there  is  inflammation  of  its  capsule, 
friction-sounds  may  be  audible  during  respiration. 

THE     PANCREAS. 

Except  in  very  thin  patients,  the  pancreas  cannot  be  felt. 
The  head  of  the  pancreas  can  sometimes  be  recognised  as  a 
small  hard  elevation,  a  little  above  and  to  the  right  of  the 
tmibilicus  :  the  body  and  tail  cannot  be  palpated.  The  genu- 
pectoral  posture  and  bimanual  pressure  from  both  sides  inwards 
are  said  to  facilitate  palpation  of  the  pancreas.  The  gland  is 
always  fixed  in  disease  as  well  as  in  health.  The  diagnosis  of 
growths  of  the  pancreas,  solid  and  cystic,  is  always  difficult 
and  sometimes  impossible,  and  many  examples  of  errors  could 
be  quoted.  I  have  had  part  charge  of  a  case  in  the  Bristol 
Infirmary  where  an  aneurism  in  the  substance  of  the  pancreas 
was,  for  more  than  a  month,  supposed  to  be  tumour  of  the 
gall-bladder. 

Other  methods  of  examination  are  absolutely  useless.  In 
growths  of  the  pancreas  lying  close  to  the  abdominal  wall, 
exploratory  puncture  may  be  employed  with  doubtful  advan- 
.  tage. 

THE      STOMACH. 

Inspection. — In  health,  some  idea  as  to  the  emptiness  or  ful- 
ness of  the  stomachic  cavity  may  be  got  by  inspection.  In 
disease,  there  is  a  marked  contrast  between  the  depression  of 
the  epigastrium  in  a  patient  with  oesophageal  obstruction  and 
the  tumefaction  of  the  upper  abdomen  seen  in  cases  of  stomachic 
distension   from  obstruction  of  the  pylorus.     Sometimes,  in  a 

3 


18  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 

dilated  stomach,  peristaltic  movements  may  be  visible  through 
the  parietes.  Not  infrequently  a  new  growth  in  the  walls  of 
the  viscus  is  visible  as  an  elevation  in  the  epigastrium. 

Palpation. — By  touch  we  can  detect  dilatation  of  the  stomach 
with  fluid  or  gas,  and  the  existence  of  growth  in  its  walls. 
Local  pain — an  important  sign  in  diseases  of  the  stomach — 
may  be  elicited  by  pressure.  A  pyloric  growth  in  its  early 
stages  is  movable ;  later  on  it  becomes  fixed.  Sometimes,  on 
account  of  dilatation  of  the  stomach,  a  p3doric  tumour  is  dis- 
placed downwards  from  the  normal  position  of  the  pylorus  in 
the  epigastrium.  Tumours  in  the  walls  of  the  stomach  descend 
by  gravitation.  Tumours  in  the  left  half  of  the  stomach,  which 
however  are  of  rare  occurrence,  cannot,  as  a  rule,  be  detected 
by  palpation.  Vermicular  contraction  of  the  stomachic  Avails 
may  occasionally  be  felt  by  the  examining  finger. 

Percussion. — Only  that  portion  of  the  surface  of  the  stomach 
which  is  in  contact  with  the  abdominal  walls  can  be  satisfac- 
torily percussed  ;  the  sounds  over  the  rest  of  the  stomach  are 
rendered  uncertain  in  import  by  the  overlapping  of  the  liver  and 
the  lung.  The  margin  of  the  left  lobe  of  the  liver  on  the  right, 
and  the  lower  border  of  the  left  lung  on  the  left,  mark  the 
upper  boundaries  of  pure  stomachic  resonance  :  the  lower  limit, 
the  great  curvature,  is  represented  by  a  curved  line  lying  mid- 
way between  the  end  of  the  sternum  and  the  umbilicus,  and 
joining  the  costal  margin  at  the  free  end  of  the  tenth  rib.  The 
upper  limits,  being  marked  by  transitions  from  hepatic  dulness 
on  the  right  and  pulmonary  resonance  on  the  left  to  the  tym- 
panitic note  given  forth  by  an  air-containing  stomach,  are  easily 
mapped  out.  The  lower  limits  are  not  so  readily  fiixed,  on 
account  of  the  proximity  of  the  colon,  which  frequently  gives 
forth  a  percussion  note  identical  in  quality  and  intensit}-. 
Sometimes,  however,  there  is  a  sharp  distinction  in  the  variety 
(jf  note,  permitting  the  hne  of  the  greater  curvature  to  be 
marked  out  with  exactitude. 

The  percussion  note  over  the  stomach  is  usually  loud  and 
tympanitic,  but  low  in  pitch.  But  the  note  varies  greatly 
according  to  the  nature  and  amount  of  contents.     The  stomach 


EXAMINATION  OF  ORGANS.  19 

may  be  quite  full  of  fluid,  when  the  note  is  dull  or  very  touch 
muffled,  and  this  dulness  may  extend  over  an  area  greater  than 
is  occupied  by  the  normal  undilated  stomach.  Air  and  fluid 
may  be  present  together,  when  each  will  give  out  its  charac- 
teristic note  according  to  its  amount  and  the  position  of  the 
patient.  A  common  condition. is  seen  when  air  and  fluid  are 
both  present  in  moderate  amount ;  and  the  stomach  surface  is 
then  represented  to  percussion  as  a  rounded  patch  of  tympanitic 
resonance  above,  bounded  below  by  a  crescentic  area  of  dulness. 
The  metallic  note  described  by  Leichtenstern,  which  may  be 
elicited  in  cases  of  over-distension  by  gas,  is  not  of  great  clinical 
value.  More  precise  results  are  sought  to  be  attained  by  such 
methods  as  that  of  Frerichs,  w^ho  generated  carbonic  acid  in  the 
cavity,  and  that  of  Schrieber,  who  inflated  a  rubber  balloon  intro- 
duced collapsed  into  the  stomach,  with  other  methods  which  might 
be  mentioned ;  but  none  of  them  have  come  into  general  favour. 

Anything  which  depresses  the  diaphragm  will  depress  the 
stomach  ;  and  anything  which  distends  the  abdomen  will  push 
the  stomach  upwards.  Its  area  of  resonance  is  diminished  by 
enlargement  of  the  liver  or  spleen,  and  increased  by  contraction 
of  the  liver,  as  well,  of  course,  as  by  gaseous  dilatation  from 
pathological  causes  proper  to  itself. 

In  every  case  important  modifications  of  the  percussion  note 
may  be  got  from  changing  the  position  of  the  patient.  Reso- 
nance follows  the  movements  of  the  gas,  always  to  the  surface  ; 
dulness  follows  the  fluid,  which  gravitates  to  the  lowest  position 
and  drags  the  stomach  with  it. 

Auscultation. — Certain  splashing,  gurgling,  or  metallic  sounds 
are  caused  by  the  agitation  of  the  fluid  and  gaseous  contents  of 
the  stomach.  These  sounds  may  be  caused  by  the  natural 
movements  of  the  stomach  walls,  or  by  rapid  voluntary  move- 
ments of  the  diaphragm,  or  by  manipulation  from  without. 
Frequently  they  are  very  loud,  and  can  be  heard  at  a  consider- 
able distance :  in  such  instances  we  may  suspect  some  sort  of 
pathological  distension.  During  the  processes  of  swallowing 
and  digestion,  gastric  murmurs,  of  a  nature  not  easily  described, 
may  be  heard  with  the  stethoscope. 

3  * 


20  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 


THE     INTESTINES. 

Inspection. — General  fulness  or  emptiness  of  the  intestines 
causes  visible  protuberance  or  retraction  of  the  abdominal  walls. 
Excessive  distension  of  the  intestines  by  gas  produces  a  charac- 
teristic form  of  enlargement.  With  general  protuberance  in  the 
umbilical  region,  there  is  a  peculiar  fulness  in  the  epigastric  and 
lumbar  regions,  which  belongs  to  no  other  form  of  abdominal 
enlargement.  In  such  cases,  if  the  parietes  are  thin,  peristaltic 
movements  may  be  seen  in  individual  coils  of  intestine.  Collec- 
tions of  faeces  in  the  colon  may  appear  as  localised  elevations  at 
any  part  of  its  course,  or  even  as  a  general  enlargement  of  the 
whole  abdomen. 

Palpation. — It  is  not  often  that  touch  is  of  assistance  in 
diagnosing  the  condition  of  intestine.  We  can  feel,  and  often 
diagnose  by  touch,  an  accumulation  of  faeces;  and  it  is  sometimes 
possible  by  palpation  alone  to  tell  whether  the  contents  of  a 
distended  bowel  are  chiefly  gaseous  or  chiefly  fluid.  Occasionally 
peristaltic  movements,  in  such  cases  of  distension,  are  perceptible 
to  touch.  One  important  sign  elicited  by  palpation  is  pain, 
chiefly  of  value  in  the  diagnosis  of  certain  inflammatory  condi- 
tions in  the  neighbourhood  of  the  caecum. 

Percussion. — In  health,  the  percussion-note  all  over  the 
intestine  is  tympanitic.  The  quality  of  the  note  varies  accord- 
ing to  the  proportions  of  fluid  or  gas  contained.  Where  the 
intestine,  still  full  of  gas,  is  of  small  calibre  from  compression, 
the  tympanitic  note  is  raised  in  pitch;  where  its  walls  are  greatly 
distended  by  gas,  the  note  becomes  deeper  in  pitch,  and  gradually, 
according  to  the  amount  of  distension,  becomes  less  and  less 
tympanitic.  In  conditions  of  extreme  gaseous  distension,  the 
character  of  the  note  is  metallic.  It  is  not  generally  known  that 
percussion  over  the  iliac  bones,  if  the  patient  is  not  fat,  will  give 
a  tolerably  accurate  idea  as  to  the  nature  of  the  contents  of  the 
underlying  bowel. 

In  certain  cases  the  presence  of  fluid  in  the  bowel  may  give 
a  dull  note  in  the  flanks,  which,  when  the  patient  turns  over, 
slowly  becomes    resonant.     In   intestinal  obstruction  that  has 


EXAMINATION  OF  ORGANS.  21 

lasted  over  a  few  days,  this  dull  lumbar  note  from  the  gravitation 
of  fluid-laden  bowels  is  of  by  no  means  infrequent  occurrence, 
I  have  more  than  once  found,  in  intestinal  obstruction,  that 
dulness  in  the  flanks,  diagnosed  as  ascites,  has  turned  out  after 
operation  to  depend  upon  large  quantities  of  fluid  in  the  bowels. 

Auscultation, — As  already  stated,  the  clinical  value  of  auscul- 
tation applied  to  the  intestine  is  not  5'et  fully  established. 
Beyond  certain  gurgling  or  splashing  sounds  produced  by  the 
mingling  of  fluid  and  gas  in  perturbed  intestinal  contractions, 
and  which  are  found  in  a  variety  of  conditions,  chiefly  medical, 
there  is  little  in  the  way  of  definite  abnormality  which  can  be 
detected  by  the  stethoscope.  In  several  cases  of  intestinal 
obstruction  it  has  appeared  to  others,  as  well  as  to  myself,  that 
those  gurgling  sounds  were  loudest  in  the  neighbourhood  of 
what  was  afterwards  found  to  be  the  situation  of  the  obstruction. 
It  is  possible  to  follow  with  the  stethoscope  the  sounds  produced 
in  the  colon  by  a  fluid  injected  through  the  rectum ;  and  this  fact 
may  be  employed  to  diagnose  the  existence  and  position  of  any 
obstruction  in  this  part  of  the  bowel. 

In  perforation  of  the  bowel,  there  are  sometimes  heard  sounds 
of  an  amphoric  or  blowing  character,  caused  by  the  gas  rushing 
out  of  the  intestinal  opening  into  the  general  peritoneal  cavity. 
These  sounds  are  said  to  be  most  audible  during  the  act  of 
inspiration. 

THE     OMENTUM. 

In  health,  the  omentum  is  beyond  the  range  of  any  of  the 
diagnostic  methods.  In  disease,  inflammatory  thickening  can  be 
detected  by  percussion  ;  and  tumours  growing  in  its  substance 
can  be  recognised  by  the  methods  proper  to  these. 

THE     UTERUS     AND     ITS     APPENDAGES. 

These  are  examined  by  methods  special  to  themselves,  which 
are  fully  described  in  works  devoted  to  the  consideration  of  their 
diseases.  Our  purpose  in  this  work  will  be  fulfilled  by  a  short 
description  of  the  method  of  palpation  as  applied  to  these 
organs. 


22  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 

The  best  position  is  generally  the  supine.  The  patient  lies 
close  to  the  edge  of  the  bed  or  couch,  and  the  thighs  are  drawn 
up  towards  the  chin  and  separated.  One  hand — the  surgeon 
ought  to  be  able  to  use  either  hand  for  the  purpose— is  laid 
upon  the  abdomen  over  the  pubes,  and  gently  but  firmly  presses 
the  pelvic  organs  downwards.  Two  fingers  of  the  other  hand 
(or  one  finger  if  there  is  a  hymen,  or  the  vagina  is  narrow  or 
tender)  are  carried  up  to  the  posterior  vaginal  cul-de-sac,  and 
the  posterior  surface  and  lateral  connections  of  the  uterus 
examined  as  far  as  possible.  We  now  seek  to  get  the  uterus 
between  the  fingers  in  the  vagina  and  the  hand  on  the  abdomen. 
If  it  is  retroverted,  we  try  to  turn  its  fundus  forwards  by  push- 
ing the  middle  finger  upwards  (supposing  two  fingers  are  used) 
in  the  cul-de-sac  behind,  while  the  forefinger,  by  a  contrary 
movement,  tries  to  pull  the  cervix  downwards  in  front.  If  it  is 
anteverted,  the  forefinger  pushes  upwards  the  vagina  in  front  of 
the  cervix,  while  the  mic^dle  finger  behind  presses  the  cervix 
downwards  and  forwards.  The  result  of  these  movements,  if 
adroitly  performed,  is  that  the  uterus  in  its  length  is  fixed 
between  the  fingers  in  the  vagina  and  the  hand  outside.  Having 
in  this  way  got  an  accurate  idea  of  the  size  and  consistence 
of  the  uterus  itself,  we  direct  attention  to  the  broad  ligaments, 
Fallopian  tubes,  and  ovaries.  We  simply  try  to  make  the  fingers 
of  each  hand  meet  over  these  organs,  palpating  their  condition 
between  them.  In  moderately  thin  patients,  with  abdominal 
walls  that  are  not  very  tense,  it  is  nearly  always  possible,  in 
health,  to  palpate  the  fundus  uteri,  and  frequently  the  ovaries 
and  broad  ligaments.  In  diseases  producing  enlargement, 
these,  and  the  Fallopian  tubes  as  well,  can  be  made  out  with 
considerable  precision.  In  diseases  not  connected  with  increase 
of  bulk,  the  production  of  pain  on  pressing  in  certain  localities 
is  a  most  valuable  aid  in  diagnosis. 

Nothing  is  said  of  the  uterine  sound.  In  bimanual  examina- 
tion, which  is  by  far  the  most  perfect  method  of  exploring  the 
uterine  organs,  its  use  is  not  called  for.  And  in  uterine  diseases 
generally  it  is  used  with  much  less  frequency  than  it  was  a  few 
years  ago.     In  cases  of  tumour,  uterine  or  doubtfully  uterine,  it 


CONDITIONS  SIMULATING  TUMOURS.  23 

will  tell  us  the  direction  which  the  uterine  canal  takes,  and,  with 
some  uncertainty,  the  length  of  the  cavity;  otherwise,  it  gives 
little  information  which  cannot  more  accurately  be  got  by  other 
means. 

In  some  cases  the  examination  is  rendered  more  complete  by 
turning  the  patient  on  her  side  in  Sims's  position,  and  examining 
after  the  manner  described.  In  this  position  the  uterine  organs 
usually  rise  upwards,  away  from  the  examining  fingers;  but  this 
disadvantage  is  sometimes  counterbalanced  by  the  greater  laxity 
of  the  tissues  in  and  around  the  vagina. 


Conditions  Simulating  Abdominal  Tumours. 

In  every  case  of  abdominal  enlargement,  we  must  be  assured 
of  the  absence  of  certain  abnormal  conditions  which  simulate 
new  growths.  The  most  important  of  these  are :  distended 
bladder,  faecal  accumulation,  phantom  tumours,  obesity  in  the 
abdominal  walls  and  omentum,  tympanites,  and  oedema  of  the 
abdominal  wall. 

Distended  Bladder. — As  no  surgeon  who  undertakes  the  surgical 
treatment  of  an  abdominal  tumour  is  likely  to  be  misled  by  this 
condition,  it  need  be  little  more  than  mentioned.  A  history  of 
retention  or  diminished  discharge  of  urine,  median  dulness  from 
the  pubes  upwards  as  far  as,  or  even  beyond,  the  umbilicus,  with 
a  rounded  fluctuating  tumour  in  this  region  and  resonance  in 
the  flanks,  are  the  ordinary  symptoms.  In  any  case  of  doubt, 
catheterisation  will  settle  the  question.  It  must  not  be  for- 
gotten, however,  that  a  distended  bladder  may  accompany  an 
abdominal  tumour.  This  may  happen  from  direct  pressure  on 
the  urethra  by  the  tumour,  or  by  stretching  of  the  urethra  by  a 
growing  tumour  which  is  adherent  to  the  bladder  wall.  Reten- 
tion of  urine  is  often  the  most  prominent  symptom  of  retroversion 
of  the  gravid  uterus. 

Facal  Accumulation. — A  collection  of  faeces  in  the  large  bowel 
may  be  mistaken  for  a  new  growth.  The  collection  may  be 
found  in  the  abdomen  wherever  the  large  bowel  may  be  found  ; 


24  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 

and  that  is,  practically,  anywhere.  It  is  now  v/ell  known, 
especially  through  the  investigations  of  Treves,  that  the  trans- 
verse colon  may  become  bent  and  elongated  so  as  quite  to  reach 
the  pubes,  and  faecal  accumulations  may  be  found  in  any  part 
of  it. 

A  tumour  of  hard  or  doughy  consistence,  occasionally  capa- 
ble of  being  moulded,  movable,  and  lying  on  the  surface  of  the 
intestines  close  to  the  abdominal  wall,  may  be  faecal.  In  size  it 
may  vary  from  that  of  a  small  orange  to  almost  any  dimension. 
When  fluid  or  semi-iluid,  its  peculiar  want  of  tension,  and  the 
absence  of  definite  fluctuation,  will  probably  strike  us.  Tym- 
panitic distension  of  the  bowel  lying  near  will  be  found  if  there 
is  obstruction  as  well  as  accumulation.  A  regular  action  of  the 
bowels  must  not  be  taken  as  contra-indicating  the  presence  of  a 
faecal  mass;  diarrhoea  even  is  not  uncommon.  In  cases  of  long- 
standing accumulation,  diarrhoea,  probably  due  to  the  formation 
of  "  stercoraceous  ulcers,"  is  the  rule  rather  than  the  exception. 

In  all  cases  the  existence  of  the  condition  will  be  proved  by 
the  administration  of  purgatives  and  enemas.  If  symptoms  of 
intestinal  obstruction  are  present,  the  chances  of  mistake  are 
diminished. 

Phantom  Tumour.  Pscudo-cycsis. — Phantom  tumour  is  a  localised 
and  symmetrical  enlargement  of  .the  abdomen,  containing  gas  ; 
pseudo-cyesis  is  the  same  associated  with  symptoms  of  preg- 
nancy. Though  similar,  the  two  conditions  are  not  identical. 
Pseudo-cvesis,  or  "  spurious  pregnancy,"  is  most  frequently 
found  in  women  who  have  married  late  in  life,  and  who  are 
anxious  for  children."-  Phantom  tumour  may  occur  in  unmarried 
women,  and  in  women  who  have  borne  children  and  are  con- 
scious that  their  condition  is  in  no  way  connected  with 
pregnancy.  Both  conditions  have  been  associated  with  hysteria. 
Rarely  is  phantom  tumour  found  in  males. 

A  case  of  ordinary  phantom  tumour  may  present  no  physical 
signs  beyond  this  tympanitic  enlargement.     A  rounded,  S3'm- 

*  An  excellent  example  of  the  species  is  depicted  with  admirable  humour 
and  effectiveness  by  Smollett  in  the  person  of  Mrs.  Trunnion,  in  reregrine 
Pickle. 


CONDITIONS  SIMULATING  TUMOURS.  25 

metrical,  movable  tumour,  of  size  varying  between  that  of  a 
large  orange  and  a  child's  head,  occupying  the  middle  of  the 
abdomen,  not  fluctuating,  and  resonant  on  percussion,  is  prob- 
ably a  phantom  tumour.  Examination  by  the  vagina  gives 
negative  information.  A  decisive  diagnosis  is  afforded  when 
the  patient  is  anaesthetised ;  the  tumour  then  disappears  spon- 
taneously, though  it  may  return  as  consciousness  returns,  or 
even  before  this. 

Pseudo-cyesis  is  a  more  complex  affair.  Though  it  is 
undoubtedly  most  common  in  elderly  women  anxious  for  chil- 
dren, and  in  whom  symptoms  of  ovarian  or  uterine  disease  are 
present,  it  occurs  also  in  young  women  in  whom  no  such 
peculiarities  exist.  The  remarkable  case  of  an  ass,  recorded  by 
Dr.  Haughton  of  Dublin,  would  seem  to  show  that  the  condition 
exists  in  the  lower  animals.  The  mimicry  of  pregnancy  is 
sometimes  very  exact.  Amenorrhoea,  swelling  of  the  breasts 
with  pigmentation  of  the  nipples,  and  morning  sickness,  may  all 
be  present  with  the  abdominal  enlargement.  At  the  presumed 
full  term  a  false  labour  may  take  place. 

In  such  cases,  Tait  thinks  that  a  power  of  air-swallowing, 
as  seen  in  crib-biting  horses,  may  account  for  the  condition. 
He  calls  attention  to  the  frequent  presence  of  loud  intestinal 
gurglings  in  these  women,  and  thinks  their  condition  is  caused 
partly  by  this  spurious  flatulence,  and  partly  by  peculiar  mus- 
cular rigidities  which  they  are  prone  to  indulge  in.  No  doubt 
the  infirmity,  if  voluntarily  produced,  is  an  outcome  of  "  tliat 
insatiable  love  of  attracting  attention  so  deeply  rooted  in  the 
female  mind,"  and  is,  as  might  be  expected,  most  frequently 
found  "in  women  to  whom  nature  has  denied  the  external 
attractions  of  beauty,  or  in  whom  there  is  not  the  compensation 
of  a  refined  and  cultured  intellect."*  Many  speculations  as  to 
the  origin  of  phantom  tumour  have  been  indulged  in  ;  probably 
Tail's  account  represents  the  full  amount  of  our  scientific 
knowledge  of  the  curious  ailment. 

Obesity  of  Abdominal  Walls  and  Omentum. — More  than  once  the 
abdominal  cavity  has  been  entered  to  remove  a  tumour  which 
*  Tait,  Dis.  of  Ovaries,  1883,  p.  206. 


26  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 

turned  out  to  be  fat.  The  simulation  of  abdominal  growths  by 
fat  in  the  parietes  or  the  omentum,  or  both,  is  sometimes  so 
close  that  considerable  care  may  be  required  in  their  discrimi- 
nation. If  obesity  is  general,  we  are  more  likely  to  be  on  our 
guard  ;  but  if,  as  sometimes  happens,  especially  near  the  climac- 
teric, there  is  a  large  deposit  of  fat  in  the  abdomen,  while  the 
limbs  do  not  increase  in  bulk,  or  even  get  thinner,  the  condition 
is  more  misleading. 

In  such  cases  the  possibility  of  grasping  and  raising  from 
the  abdominal  muscles  masses  of  fatty  tissue,  the  absence  of 
any  localised  area  of  dulness,  and  the  negative  results  of  vaginal 
examination,  will  be  our  chief  guides  in  diagnosis.  A  fat 
omentum  is  clinically,  perhaps,  an  abdominal  tumour ;  but 
pathologically,  there  is  no  growth  of  similar  thickness  and 
consistency  which  is  spread  so  evenly  over  the  bowels. 

Qldeina  of  Abdominal  Wall. — Great  oedema  of  the  abdominal 
Avail  has  been  mistaken  for  abdominal  tumour  ;  but  the  error 
must  be  of  rare  occurrence.  A  concomitant  thickness  and 
hardness  of  the  subcutaneous  tissues,  preventing  pitting  on 
pressure,  would  seem  to  be  necessary  to  render  the  mistake 
even  possible.  The  absence  of  all  the  physical  signs  of  abdo- 
minal tumour  except  increase  in  size,  with  the  presence  of 
such  signs  of  disease  in  the  system  as  would  account  for  the 
oedema,  should  help  the  diagnosis.  It  should  be  remembered, 
however,  that  oedema  sometimes  accompanies  abdominal 
tumour. 

Tympanites. — At  least  seven  cases  are  on  record  where  an 
abdomen  has  been  laid  open  to  find  only  gas.  In  phantom 
tumour  this  would  be  impossible,  for  the  swelling  disappears 
with  the  anaesthesia.  The  mistake,  in  the  light  of  our  present 
knowledge,  seems  almost  inexcusable.  On  the  other  hand,  it  is 
just  possible  to  overlook  the  presence  of  a  tumour  because  it  is 
resonant  all  over  its  surface.  I  have  removed  a  large  putrid 
suppurating  cyst,  over  the  whole  surface  of  which  resonance 
could  be  demonstrated  on  the  operating  table  to  a  number 
of  students  and  medical  men.  Half  its  contents  were 
gaseous. 


CLASSIFICATION  OF  TUMOURS.  27 

Having  eliminated  these  spurious  complaints,  and  having 
decided  that  the  abdomen  contains  a  real  tumour — a  foreign 
development  constituting  disease — our  next  duty  is  to  make  out 
what  this  tumour  is.  In  working  out  the  diagnosis,  it  is  well  to 
follow  certain  lines  with  the  mind  that  reasons,  as  well  as  with 
the  senses  that  explore.  These  lines  need  not  be  laid  down  by 
science ;  they  may  be  purely  practical,  if  only  they  are  useful. 
Our  purpose  being  simply  diagnosis,  we  are  justified  in  adopting 
any  procedure  which  will  most  quickly  and  certainly  bring  out 
the  ph3'sical  features  of  the  disease.  Thus,  while  we  group 
together  all  tumours  of  the  ovarj^  for  purposes  of  classification 
and  description,  for  diagnosis  we  rather  compare  solid  tumours 
of  the  ovary  with  pedunculated  m3-omata  of  the  uterus.  A 
large  ovarian  cyst  may  have  more  physical  signs  in  common 
with  a  cyst  of  the  kidney  than  with  any  pathologicall}'-  allied 
growth,  uterine  or  ovarian. 

The  rarity  of  a  disease  may  be  a  cause  of  meagre  scientific 
acquaintance  with  it ;  but  for  diagnostic  purposes,  all  diseases 
have  equal  importance.  In  abdominal  surgery,  in  particular,  it 
is  just  those  rare  diseases  that  we  chiefly  wish  to  exclude. 
Probably,  most  of  the  errors  in  abdominal  surgery  are  made  in 
this  way.  The  ordinar}'^  broad  signs  of  ovarian  disease  may  in 
a  score  of  cases  have  guided  our  diagnosis  correctly,  when  a 
twenty-first  case  turns  up  with  an  exact  repetition  of  all  these 
signs,  and  we  find  ourselves  in  error.  We  have  probably  over- 
looked one  or  two  little  signs  of  the  rare  disease,  because  we 
thought  little  of  it.  We  dare  not  essay  to  perform  operations 
on  the  abdomen  till  we  are  familiar  with  the  diagnosis  of  all 
abdominal  tumours;  and  we  cannot  pretend  to  diagnose  posi- 
tively any  one  disease  without  being  able  negatively  to  exclude 
every  other. 

From  the  purely  diagnostic  point  of  view  I  have  arranged 
the  following  plan.  It  is  one  which  I  have  unconsciously 
adopted  in  abdominal  examinations,  and  I  present  it  simply  as 
being  likely  to  be  useful.  It  is,  of  course,  a  mere  skeleton, 
indicating  in  a  few  words  the  most  prominent  and  characteristic 
signs  which   suggest,   but   do   not   prove,  the  existence  of  the 


28  DIAGNOSIS  OF  ABDOMINAL  TUMOURS. 

disease.      Full    diagnostic    details   will    be    found    under    the 
headings  of  the  various  diseases  described. 

The  classification  is  based  on  the  most  prominent  physical 
signs.  The  first  question  asked  is,  Is  the  tumour  solid  or  fluid  ? 
The  next  question  is,  Is  it  in  the  middle  line,  or  on  one  side  ? 
i.e.,  Is  it  symmetrical  or  non-symmetrical,  with  regard  to  the 
general  abdominal  surface?  If  it  is  non- symmetrical,  On 
which  side  does  it  lie  ?  If  it  is  symmetrical.  Does  it  lie  in  the 
upper  or  lower  abdomen,  or  in  the  middle  ?  By  answering  these 
simple  questions  at  each  step  in  our  examination,  we  narrow 
the  limits  of  possible  disease  twofold,  fourfold,  and  eightfold,  at 
the  first,  second,  and  third  steps  respectively. 

Schematic  Arrangement  of  Abdominal  Tumours 
for  Purposes  of  Diagnosis. 

SOLID  TUMOURS. 

Symmetrical. 

Upper  Abdomen.  —  Cancer  of  Pancreas.  Cancer  of 
Pylorus.  Fibroid  Thickening  of  Pylorus.  Morbid 
Growths  in  Stomach. 
Lower  Abdomen.  —  Solid  Growths  of  Ovary  —  Sar- 
coma, Fibroma,  Carcinoma.  Uterine  Myoma.  Sar- 
coma of  Uterus.  Molar  Pregnancy.  Extra-uterine 
Pregnancy  (also  fluid). 

NoN- SYMMETRICAL. 

Either  side  of  Abdomen. — Solid  Growths  of  Kidney — 
Sarcoma,  Adenoma,  Carcinoma.  Displaced  Kidne}^ 
Tumours  of  Colon. 

Right  Side. — Solid  Growths  of  Liver — Sarcoma,  Carci- 
noma. Solid  Tumours  of  Gall  bladder.  Cancer  of 
Caecum. 

Left  Side. — Enlargements  of  Spleen — Leucocytha^mic, 
Amyloid,  Cancerous,  Syphilitic.    Wandering  Spleen. 

Indifferently  Situated. 

Solid  Growths  of  Peritoneum — Cancer,  Enchondroma. 
Cancer  of  Omentum.  Cancer  and  Sarcoma  of 
Parietes. 


SCHEMATIC  ARRANGEMENT  OF  TUMOURS.  29 

FLUID  TUMOURS. 

Symmetrical. 

upper  and  Middle  Abdomen. — Cysts  of  Pancreas.  Peri- 
toneal and  Mesenteric  Cysts.  Encysted  Dropsy  of 
Peritoneum. 
Lower  Abdomen. — Ascites.  Ovarian  Cystoma.  Parovarian 
Cysts.  Papillomatous  Cysts  of  Broad  Ligament. 
Fibro-cysts  of  Uterus.  Pregnancy.  Hydramnios. 
Haematometra.  Haematokolpos.  Hydrometra.  Extra- 
uterine Pregnancy.     Cysts  of  Urachus. 

NON-SYMMETRICAL. 

Either  Side. — Renal  Cysts.  Renal  Hydatids.  Hydro- 
nephrosis. Pyo  -  nephrosis.  Nephric  and  Peri- 
nephric Abscess.  Hydro-  Haemato-  Pyo -salpinx. 
Extra-uterine  Pregnancy.     Ovarian  Abscess. 

Right  Side. — Abscess  of  Liver.  Hydatids  of  Liver. 
Dropsy  and  Empyema  of  Gall-bladder. 

L'eft  Side. — Abscess  of  Spleen.     Hydatids  of  Spleen. 


Solid  Tumours. 

It  is  impossible  to  define  the  meaning  of  the  clinical  term 
"  solidity  "  applied  to  tumours.  Negatively,  it  has  been  taken 
as  meaning  "absence  of  fluctuation;"  but  this  is  inexact,  for 
many  fluid  tumours  do  not  fluctuate.  And  more  than  one  class 
of  tumour  which  is  pathologically  solid  may  give  an  obscure 
sense  of  fluctuation.  It  would  be  near  the  truth  to  say  that 
most  solid  tumours  are  hard,  that  they  communicate  to  the 
hand  a  peculiar  sense  of  resistance,  that  none  fluctuate  freely, 
and  that  very  few  fluctuate  even  obscurely.  But,  undoubtedly, 
the  best  ultimate  criterion  of  solidity  and  fluidity  in  tumours  is 
the  educated  sense  of  touch.  A  skilled  and  experienced  diag- 
nostician will  say  almost  at  once,  by  laying  his  hand  on  a  growtli, 
whether  it  is  solid  or  fluid  ;  and  such  judgment,  in  my  opinion, 
is  more  likely  to  be  correct  than  the  most  painstaking  enquiry 
into  all  the  clinical  features  of  the  enlargement. 


Solid  Symmetrical  Tumours. 

By  a  symmetrical  tumour  is  meant  one  which  occupies  equal 
parts  of  each  side  of  the  abdomen.  The  symmetry  of  the 
abdomen  is  not  disturbed;  the  enlargement  is  bilaterall}-  equal, 
or  nearly  so. 

SOLID    SYMMETRICAL    TUMOURS    IN    THE    UPPER    ABDOMEN. 

Cancer  of  the  Pancreas. — A  hard,  rounded  or  irregular  tumour 
fixed  deeply  in  the  region  of  the  pancreas,  usually  covered  by 
bowel,  and  perhaps  giving  a  sense  of  pulsation  to  palpitation, 
with  a  vascular  bruit  on  auscultation,  is  probably  pancreatic 
cancer.  If  the  growth  is  small,  nothing  may  be  detected  beyond 
a  deep,  obscure  sense  of  resistance  and  hardness.  It  is  not 
often  that  the  growth  acquires  dimensions  large  enough  to  be 
visible  through  the  abdominal  wall. 

Cancer  of  the  Pylorus. — This  may  be  felt  as  a  small  hard 
movable  tumour  situated  in  the  epigastrium,  usually  a  little  to 
the  right  of  the  median  line.  It  becomes  fixed  in  its  later 
stages.  It  always  lies  deeply,  and  is  covered  by  bowel.  Pres- 
sure causes  pain. 

Fibroid  Thickening  of  the  Pylorus. — Although  thickening  of  the 
pylorus  rarely  reaches  to  the  dimensions  of  a  tumour,  it  some- 
times becomes  bulky  enough  to  be  obscurely  felt  as  a  localised 
induration.  From  the  early  stages  of  cancer  of  the  pylorus,  it 
cannot  be  diagnosed.  The  amount  of  pain  elicited — small  in 
thickening,  considerable  in  cancer — may  be  of  value. 

Morbid  Groivths  in  the  Stomach. — These  are  roughly  median, 
but  usually  with  the  main  enlargement  on  the  left.  They  are 
usually  one  or  other  of  the  varieties  of  cancer,  three-fourths  of 
the  cases  being  scirrhus.  A  growth  in  the  stomach  is  at  first 
freely  movable,  near  the  surface  if  in  the  anterior  wall  or 
greater  curvature,  rounded  or  irregular  in  outline,  and  may 
attain  to  a  considerable  size.  On  the  posterior  surface  or  lesser 
curvature  (which  is  not  a  common  situation),  the  growth  may  be 
only  obscurely  palpable  when  the  stomach  is  empty.  It  tends  to 
drag  the  stomach  downwards,  and  from  this  cause,  as  well  as 


SCHEMATIC   ARRANGEMENT  OF   TUMOURS.  31 

from  the  dilatation  of  the  viscus  which  usually  accompanies  it> 
may  descend  as  low  as  the  umbilicus.  It  is  painful  on  palpa- 
tion. I  have  seen  two  cases  of  cancer  of  the  posterior  wall,  in 
each  of  which  there  was  a  visible  protuberance  in  the  epigas- 
trium. Cancers  of  the  stomach  are  late  in  becoming  fixed ; 
some  slight  degree  of  mobility  is  present  to  the  last. 


SOLID    SYMMETRICAL    TUMOURS    IN    THE    LOWER    ABDOMEN. 

Solid  Growths  of  the  Ovary  (sarcoma,  fibroma,  myoma,  carci- 
noma) present  clinical  features  which  are,  except  where  the 
tumours  are  of  large  size,  essentially  identical.  When  they  first 
signify  their  presence,  the}'  are  usually  about  the  size  of  the  fist, 
and  have  escaped  from  the  pelvic  into  the  abdominal  cavity. 
Unless  they  are  of  considerable  size,  they  are  not  strictly  sym- 
metrical, lying  towards  the  side  of  the  ovary  from  which  they 
spring ;  but  as  they  occup)^  more  of  the  middle  than  of  the 
sides  of  the  abdomen,  they  may  be  considered  as  symmetrical. 
When  large,  the}'  become  strictly  median. 

Such  tumours  are  round,  hard,  smooth  on  the  surface  and 
freely  movable.  They  are  not  usually  very  painful  on  being 
handled.  Vaginal  examination  reveals  a  normal  uterus,  some- 
times dragged  upwards,  movable,  and  following  upwards  artificial 
elevation  of  the  growth.  By  deep  exploration  with  the  fingers, 
it  may  be  possible  to  make  out  tension  and  relaxation  of  the 
ovarian  ligaments  as  the  tumour  is  pulled  upwards  or  pushed 
downwards.  Palpation  reveals  the  sensation  that  the  uterus 
is  not  closely,  but  remotely  attached  to  the  tumour.  This 
condition  may  be  verified  by  passage  of  the  uterine  sound. 

Uterine  Myoma. — This  enlargement  varies  in  its  appearance 
according  as  it  is  sessile  or  pedunculated,  single  or  multiple, 
hard  or  soft  ("  oedematous  "),  fixed  in  the  pelvis  or  free  in  the 
abdominal  cavity.  A  single  round  pedunculated  myoma  may 
be  very  similar  in  clinical  features  to  a  solid  ovarian  tumour.  It 
is  more  exactly  median,  and  the  uterus  follows  its  movements 
more  closely.  The  sessile  myoma  has  more  of  its  bulk  low  down 
than  the  pedunculated,  and  the  uterus  seems  to  be  part  of  it, 


32  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

following  its  movements  to  the  fullest  extent.  Multiple  myomata 
exhibit  several  rounded  bosses  irregularly  placed  in  the  lower 
abdomen,  and  are  usually  associated  with  considerable  enlarge- 
ment of  the  uterine  tissues,  with  elongation  of  the  uterine  cavity. 
The  distinctive  signs  of  the  individual  varieties  of  myomata 
need  not  here  be  referred  to.  There  is  practically  no  limit, 
consistently  with  life,  to  the  size  to  which  these  tumours  may 
grow.  Auscultation  over  myomatous  growths  may  reveal  a 
vascular  bruit. 

Sarcoma  of  the  Utenis. — It  is  very  seldom  that  sarcoma  of  the 
uterus,  in  itself  a  rare  disease,  attains  to  such  a  size  as  to  become 
an  abdominal  tumour.  Its  growth  is  usually  purely  intra-uterine 
and  the  uterine  walls  are  spread  over  it.  From  a  large  fibroid 
polypus,  it  cannot  be  diagnosed  with  certainty :  softness  and 
rapidity  of  growth  suggest  sarcoma. 

Molar  Pregnancy. — This  is  recognised  as  being  an  intra-uterine 
enlargement  by  the  ordinary  methods  of  physical  examination. 
The  hydatidiform  mole  is  said  to  reveal  to  palpation  "  a  pecu- 
liar doughy  boggy  feeling,  in  the  highest  degree  characteristic' 
The  abdominal  tumour,  which  may  increase  more  rapidly  than 
a  normal  gestation,  and  grow  to  a  greater  size,  is  usually  some- 
what flattened.  The  principal  signs  in  such  cases  are  merely 
confirmatory  of  the  more  important  general  symptoms  which 
accompany  this  form  of  abnormal  gestation. 

Extra-uterine  Pregnancy. — When  the  foetus  is  dead,  and  the 
surrounding  fluids  are  absorbed,  an  extra- uterine  pregnancy 
may  appear  as  a  hard  irregularly-rounded  mass  fixed  in  the 
lower  abdomen  and  pelvis.  Its  connections  with  the  uterus, 
which  is  always  enlarged,  are  close  and  firm.  Here  also  history 
is  all-important  in  forming  a  diagnosis.  It  may  be  impossible, 
so  far  as  physical  signs  are  concerned,  to  diagnose  a  uterine 
myoma  from  an  extra-uterine  pregnancy. 

Solid  Non-symmetrical  Tumours. 

By  a  non-symmetrical  tumour  is  meant  one  which,  visibly 
or  palpably,  lies  chiefly  in  and  has  its  main  connections  on 


SCHEMATIC  ARRANGEMENT  OF  TUMOURS.  33 

one  side  of  the  abdomen.  The  symmetry  of  the  abdomen, 
if  there  is  evident  enlargement,  is  disturbed.  If  there  is  no 
enlargement,  an  abnormal  swelling  is  felt  in  one  side  of  the 
cavity. 

SOLID    NON-SYMMETRICAL   TUMOURS    FOUND    ON    EITHER    SIDE 
OF    THE    ABDOMEN. 

Solid  Growths  of  the  Kidney. — These  are :  sarcoma,  several 
varieties;  adenoma;  and  carcinoma.  Clinically,  certain  suppu- 
rative lesions  of  the  kidney  may  be  solid.  From  mere  increase 
of  resistance  in  the  loin  without  visible  enlargement,  to  a  bulk 
so  great  that  it  may  pass  the  middle  line  and  even  fill  the  whole 
abdominal  cavity,  there  is  every  gradation  of  size  in  renal 
tumours.  Generally  speaking,  a  hard  smooth  body,  fixed  or  but 
slightly  movable,  in  either  loin,  dull  on  percussion  from  the 
lumbar  region  forwards,  and  completely  filling  the  costo-iliac 
space,  will  indicate  a  solid  renal  growth.  Pressure  on  a  renal 
tumour  from  the  front  gives  a  peculiar  sense  of  hard,  unyielding 
resistance.  In  tumours  of  considerable  size,  the  passage  of  the 
colon — ascending  or  descending,  as  the  case  may  be — over  its 
surface  may  be  detected  by  percussion  or  palpation. 

Displaced  Kidney,  movable  and  fixed. — A  movable  and  a  floating 
kidney,  pathologically  distinct,  give  identical  physical  signs. 
A  body  of  the  size,  shape,  and  consistence  of  the  kidney  is  felt 
somewhere  in  the  abdomen  between  its  normal  situation  and 
the  middle  line  :  it  glides  from  under  the  palpating  fingers,  and 
may  be  replaced  in  the  loin,  when  its  presence  may  be  detected 
by  bimanual  palpation.  It  is  always  covered  by  bowel.  A 
peculiar  sensation  of  nausea  and  faintness  is  produced  by  pres- 
sure.    Movable  kidney  is  most  common  on  the  right  side. 

A  kidney  fixed  in  an  abnormal  situation  is  usually  found 
near  the  brim  of  the  pelvis,  close  to  the  sacro-iliac  joint.  It  is 
usually  larger  and  more  lobulated  than  natural,  but  otherwise 
presents  to  the  examining  finger  the  physical  characters  of  renal 
substance.  Fixed  malposition  of  the  kidney  is  most  frequently 
met  with  on  the  left  side.  Manual  exploration  by  the  rectum 
may,  in  certain  cases,  be  necessary  for  diagnosis. 

4 


34  DIAGNOSIS  OF  ABDOMINAL   TUMOURS. 

Tumours  of  the  Colon. — Solid  growths  of  the  colon  are — poly- 
pus, adenoma  or  adeno-sarcoma,  and  cancer.  A  polypoid 
growth  is  usually  found  in  the  descending  colon  ;  it  is  rarely 
so  large  as  an  orange,  and  is  freely  movable  for  some  inches  in 
all  directions.  It  lies  usually  at  or  near  the  surface  of  the 
abdomen.  In  the  sigmoid  flexure  it  is  perceptible  on  rectal 
palpation.  Cancer  may  be  found  in  any  part  of  the  large 
bowel.  It  is  felt  rather  as  an  obscure  thickening  than  as  a 
distinct  rounded  tumour,  and  is  slightly  or  not  at  all  movable. 
For  diagnosis,  other  signs,  especiallj^  those  found  in  the  excreta, 
are  essential. 


NON-SYMMETRICAL    SOLID    GROV/THS    ON    THE    RIGHT    SIDE 
OF    THE    ABDOMEN. 

Solid  Groivths  of_  the  Liver. — Various  kinds  of  cancer  and 
sarcoma  are  found  affecting  the  liver,  as  new  growths  ;  it  may  be 
enlarged  from  fatty  or  lardaceous  disease,  or  other  influences 
which  do  not  here  concern  us.  The  leading  physical  signs  in 
malignant  disease  are,  a  solid  resisting  enlargement  in  the  hepatic 
region — most  frequently  in  the  right  lobe,  rarely  in  the  left  lobe 
— causing  more  of  its  surface  than  is  natural  to  protrude  from 
under  the  ribs,  and  increasing  the  area  of  dulness.  From  the 
upper  limits  of  hepatic  dulness  over  the  ribs  to  the  lower 
limits  of  the  enlargement  in  the  abdomen,  dulness  on  percussion 
is  continuous.  If  the  enlargement  is  not  very  great,  and  if  the 
growth  is  not  adherent,  the  liver  moves  upwards  and  downwards 
during  respiration.  The  characteristic  knobs  on  the  surface  of 
the  liver,  in  cancer,  are  almost  pathognomonic.  The  edge  of 
the  liver  may  be  palpated.  There  is  practically  no  limit,  other 
than  the  capacity  of  the  abdomen,  to  the  growth  of  malignant 
tumours  of  the  liver. 

Solid  Tumour  of  the  Gall-bladder. — Except  as  part  of  general 
malignant  disease  of  the  liver,  new  growths  in  the  gall-bladder 
are  rare.  A  gall-bladder  full  of  gall-stones,  and  with  walls 
thickened  from  inflammation,  is  clinically  a  solid  tumour.  A 
tumour  of  the  gall-bladder  appears  in  its  normal  situation  at  the 


SCHEMATIC  ARRANGEMENT  OF  TUMOURS.  35 

edge  of  the  liver,  and  grows  diagonally  downwards  and  inwards 
towards  the  umbilicus.  It  is  smooth  and  rounded  on  the  surface, 
globular,  ovoid,  or  pear-shaped  in  outline,  and  is  movable  in 
lateral  directions,  and  to  some  extent  backwards.  Dulness  over 
it  is  rarely  absolute ;  an  area  of  resonance,  from  the  presence 
of  colon,  is  occasionally  found  separating  it  from  the  liver 
margin. 

Cancer  of  the  CcEcum. — A  hard  irregular  tumour,  not  of  large 
size,  in  the  right  iliac  fossa,  and  movable  through  a  limited  area, 
may  be  a  malignant  growth  in  the  caecum.  Other  signs,  relating 
chiefly  to  obstruction  to  the  passage  of  the  intestinal  contents, 
are  necessary  to  the  diagnosis.  Inflammation  in  the  caecum,  or 
near  it  (typhlitis  or  peri-typhlitis),  may  be  associated  with  the 
development  of  an  enlargement  which  simulates  new  growth : 
in  this  case  the  enlargement  is  not  movable.  A  malignant 
tumour  in  this  part  of  the  bowel  is  not  usually  strictly  limited 
to  the  caecum,  but  involves  either  ileum  or  ascending  colon. 


NON-SYMMETRICAL    SOLID    GROWTHS    ON    THE    LEFT    SIDE    OF 
THE    ABDOMEN. 

Solid  Enlargements  of  the  Spleen. — With  the  diagnosis  of  the 
acute  enlargements  of  the  spleen  found  in  various  purely  medical 
diseases  we  are  not  here  concerned.  The  varieties  of  splenic 
enlargement  likely  to  be  met  with  in  exploration  of  the  abdomen 
for  tumours  arise  from  Leucocythaemia,  Amyloid  degeneration, 
Cancer,  and  Syphilis.  In  all  of  these,  physical  examination 
reveals  little  more  than  enlargement  of  the  organ.  Splenic 
tumours  appear  under  the  left  false  ribs,  and  grow  downwards 
and  inwards  towards  the  middle  line.  They  lie  close  to  the 
parietes,  and  give  an  absolutely  dull  note  on  percussion  over 
the  surface ;  there  is  usually  an  area  of  resonance  in  the  loin 
behind.  The  characteristic  notched  or  festooned  inner  border 
is  usually  to  be  felt.  Unless  the  tumour  is  of  considerable 
size — and  splenic  tumours  may  attain  to  great  dimensions — 
it  enjo3^s  some  degree  of  mobility.  Palpation  in  most  cases 
is  painless. 

4  * 


36  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

Wandering  Spleen. — This  rare  condition  is  found  exclusively  in 
women.  A  displaced  spleen  has  been  found  at  the  umbilicus, 
in  the  true  pelvis,  and  at  various  other  situations  in  the  left 
abdomen.  In  one  case,  at  least,  it  has  been  found  free  in  the 
cavit}^,  the  pedicle  having  been  twisted  through.  Absence  of 
dulness  at  the  normal  site  of  the  spleen,  and  the  presence  of 
a  body  having  the  physical  characters  of  this  organ,  movable 
round'  a  centre  placed  under  the  left  false  ribs,  is  probably 
wandering  spleen.  A  dislocated  spleen  is,  however,  liable  to 
contract  adhesions  in  its  abnormal  position,  and  then  mobility 
is  absent. 


SOLID    TUMOURS    INDIFFERENTLY   SITUATED    IN    THE 
ABDOMINAL    CAVITY. 

Tumours  of  the  omentum,  the  peritoneum,  the  small  intes- 
tines, and  the  parietes,  may  appear  at  any  part  of  the  abdominal 
area.  Their  situation  is  indifferently  lateral  or  median,  high  up 
or  low  down. 

Solid  Growths  of  the  Peritoneum. — Excluding  tubercular  disease, 
the  new  developments  met  with,  in  connection  with  the  peri- 
toneum, are  practically  all  cancerous.  Enchondroma  has  been 
found  as  a  new  growth,  originating  from  the  peritoneum.  In  the 
great  majority  of  cases,  peritoneal  cancer  is  secondary  either  to 
outlying  disease  or  to  local  disease  in  the  intestines.  As  usually 
met  with,  cancer  of  the  peritoneum  is  sessile,  very  hard  and 
irregular  on  the  surface,  and  accompanied  by  a  variable  amount 
of  ascitic  fluid.  If  originating  from  the  bowel,  and  seen  early,  it 
may  be  movable  ;  but  it  very  soon  becomes  fixed,  by  implication 
of  neighbouring  organs.  In  most  cases  bowel  either  overlies  it 
or  passes  through  it,  and  thus  gives  a  percussion  note  of  reso- 
nance or  modified  dulness.  In  cases  of  advanced  disease,  a  large 
amount  of  ascitic  fluid  may  be  present,  masking  the  signs  and 
obscuring  the  diagnosis. 

Solid  growths  of  the  small  intestine  not  involving  the 
peritoneum  are  mere  pathological  curiosities,  and  may  be 
practically  ignored. 


SCHEMATIC  ARRANGEMENT  OF  TUMOURS.  37 

Solid  Growths  of  the  Omentum. — Various  forms  ot  malignant 
disease  may  attack  the  omentum  ;  colloid  cancer  is  the  most 
important.  It  is  known  by  its  superficial  position,  overlying  the 
bowels ;  by  its  very  irregular  surface,  hard  at  most  parts,  but 
boggy  or  even  semi-fluctuating  where  colloid  material  abounds ; 
and  by  the  wide  superficies  which  it  occupies,  as  compared  with 
its  general  bulk.  Ascites,  revealed  by  the  ordinary  signs,  may 
be  present  behind  the  growth.  In  the  earliest  stages  of  omental 
cancer,  palpation  and  deep  percussion  may  elicit  signs  that  it 
overlies,  and  is  supported  by,  intestines. 

Solid  Groivths  of  the  Abdominal  Parietes. — These  are  usually 
malignant,  most  frequently  cancerous,  but  sometimes  sarco- 
matous. They  cause  bulgmgs  ot  the  parietes,  more  prominent 
than  their  size  would  seem  to  warrant ;  are  rounded,  and  not 
very  irregular  on  the  surface ;  they  follow  closely  the  move- 
ments of  the  abdominal  walls,  and,  if  of  moderate  size,  appear 
to  float  on  the  surface  of  the  intestines.  There  .is  absolute 
dulness  all  over  the  palpable  surface. 


Fluid  Tumours. 

The  only  definite  attribute  that  can  be  attached  to  the 
clinical  term  "fluidity,"  apphed  to  new  growths,  is  "presence 
of  fluctuation."  Many  tumours,  however,  that  have  fluid  con- 
tents, and  that  are  diagnosed  as  having  such,  do  not  exhibit  the 
sign  of  fluctuation.  Between  the  definite  physical  signs  of 
fluidity  and  solidity  there  are  gradations  which  we  seek  to 
describe  by  such  terms  as  "soft,"  "boggy,"  "semi-fluctuating," 
But  the  actual  condition,  solid  or  fluid,  is  in  many  instances  a 
thing  to  be  decided  simply  and  solely  by  the  educated  sense  of 
touch.  So  many  circumstances  combine  to  obscure  or  abolish 
the  sign  of  fluctuation,  even  when  it  ought  to  be  present,  that 
special  pains  should  be  taken  to  perfect  our  means  of  diagnosis 
without  this  sign.  Thick  abdominal  walls,  tension  or  thickness 
in  the  cyst-wall,  great  density  of  the  fluid,  or  multiplicity  of  the 
loculi  in  which  the  fluid  is  contained,  are  some  of  the  hindrances 


38  DIAGNOSIS   OF  ABDOMINAL    TUMOURS. 

to  fluctuation.  We  conclude,  therefore,  that  while  the  positive 
sign — fluctuation — is  proof  of  fluidity,  its  absence  is  not  proof 
to  the  contrary  ;  and  that,  though  no  verbal  description  of  it  is 
possible,  the  educated  sense  of  touch  must  frequentl}^  be  our 
sole  guide. 

FLUID    SYMMETRICAL    TUMOURS    IN    THE    UPPER    AND    MIDDLE 
ABDOMEN. 

Cysts  of  the  Pancreas. — Though  not  always  accurately  sym- 
metrical, cysts  of  the  pancreas  lie  mainly  in  the  middle  line. 
A  rounded  thin-walled  cyst,  distinctly  fluctuating,  deeply  and 
firmly  fixed,  not  moving  with  respiration,  and  situated  above 
the  umbilicus,  may  be  a  pancreatic  cyst.  Exploratory  punc- 
ture reveals  a  fluid,  viscid  or  opalescent,  alkaline  in  reaction, 
and  containing  a  considerable  amount  of  albumen,  which  is 
coagulated  by  heat  and  nitric  acid. 

Peritoneal  and  Mesenteric  Cysts.  Encysted  Dropsy  of  the  Peri- 
toneum.— Like  pancreatic  cysts,  these,  though  chiefly  occupying 
the  middle  line,  are  rarely  exactly  median.  It  is  impossible  to 
diagnose  them  with  precision.  They  clearly  contain  fluid, 
though  fluctuation  is  usually  obscure ;  it  is  rarely  possible  to 
make  out  a  distinctly  outlined  cyst-wall,  as  intestine  is  frequently 
intimately  attached  to  its  surface,  and  the  percussion  notes  are 
liable  to  vary  at  different  times  of  examination.  Some  degree 
of  mobility  is  usually  present.  Such  collections  are  usually 
situated  either  at  the  level  of,  or  below,  the  umbihcus;  occasion- 
ally, however,  they  are  found  elsewhere. 


FLUID    SYMMETRICAL    ENLARGEMENTS    IN    THE    LOWER    ABDOMEN. 

Ascites.  Peritoneal  Dropsy. — A  fluctuating  fluid  collection  in 
the  abdominal  cavity  that  changes  position  with  the  movements 
of  the  patient,  always  gravitating  to  the  lowest  part  of  the 
cavity  and  causing  dulness  on  percussion  there,  but  leaving 
resonant  the  highest  part,  or  situations  from  which  bowel  cannot 
be  displaced,  is  probably  ascites.     In  the  supine  position,  there 


SCHEMATIC   ARRANGEMENT  OF  TUMOURS. 


39 


is  dulness  in  the  flanks ;  and  if  the  amount  of  fluid  is  not  very- 
great,  there  is  resonance  in  front,  over  a  circular  or  crescentic 
area  the  concavity  of  which  is  towards  the  chest.  (Fig.  2.)  If 
the  parietes  are  not  greatly  distended,  the  abdomen  is  flattened; 
if  its  walls  are  lax,  there  may  be  bulging  in  the  flanks.  In  cases 
of  great  distention,  the  umbilicus  protrudes.  Vaginal  exami- 
nation gives  negative  results. 

Ovarian  Cystoma. — A  rounded  or  irregular  tumour  in  the 
middle  line,  or  slightly  to  one  side,  always  showing  its  presence 
in  front  to  palpation  or  percussion,  never  changing  its  shape, 
and  movable  only  in  mass  or  not  at  all,  may  be  an  ovarian  cyst. 
In  the  supine  posture  there  is  a  circular  area  of  dulness,  sur- 
rounded by  a  "tympanic  corona"  ;  if  no  ascites  is  present,  there 
is  resonance  in  the  flanks.     (Fig.  3.)     There  is  no  protrusion  of 


Fig  2. 


Fig  3. 


Diagrams  showing  development  of  areas  of  dulness  in  ascites  (Fig.  2),  and  in  ovarian 
tumour  (Fig.  3^.     Darker  shading  indicates  an  earlier  stage  of  disease. 


the  umbilicus.  Vaginal  examination  reveals  close  or  remote 
connection  with  the  uterus,  with  displacement,  and  sometimes 
enlargement,  of  that  organ. 

Parovarian    Cysts. — This  variety  of  growth  has  the  character 
of  the  preceding,  as  to  dulness  in  front   and  resonance  in  the 


40  DIAGNOSIS   OF  ABDOMINAL  TUMOURS. 

flanks.  The  cyst  is  thin-walled,  and  fluctuation  is  very  evident. 
By  the  vagina  it  may  frequently  be  palpated,  when  its  thin  wall 
and  connection  with  the  uterus  through  the  broad  ligament  will 
confirm  the  diagnosis. 

Papillomatous  Cysts  of  the  Broad  Ligament. — These  are  not 
usually  diagnosed  from  ovarian  cystomata.  They  are  firmly 
fixed  low  down  in  the  pelvis,  and  are  frequently  closely  incor- 
porated with  the  uterus.  One  or  more  large  cysts,  not  often 
symmetrical,  and  with  sulci  between  them,  occupy  the  abdo- 
men :  by  vaginal  examination,  several  cysts  of  smaller  size  may 
be  detected  in  the  pelvis.  Small  growths  of  this  nature  are 
one-sided. 

Fihvo-cystic  Disease  of  the  Uterus. — It  is  probable  that  ovarian 
or  broad  ligament  cysts  have  been  not  infrequently  described  as 
cystic  disease  of  the  uterus.  True  cystic  disease  is  undoubtedly 
very  rare.  In  very  few  cases  can  it  be  diagnosed  from  ovarian 
cystoma.  It  has  most  of  the  signs  of  the  latter,  and  is  always 
sessile  on  the  uterus,  moving  consentaneously  with  that  organ. 
Many  ovarian  tumours  are  very  intimately  attached  to  the 
uterus. 

Pregnancy. — K  pregnant  uterus  stands  out  from  the  pelvis 
more  prominently  than  an  ovarian  or  other  tumour  of  the  same 
size :  more  of  the  fundus  is  palpable  than  in  other  tumours. 
The  uterine  walls  are  of  a  peculiar  density,  fluctuation  is 
obscure,  and  the  foetus  may  be  felt  by  palpation  or  ballottement. 
By  the  vagina,  there  is  detected  a  characteristic  softening  of  the 
cervix — not  merely  the  superficial  softening  of  swollen  mucous 
membrane,  but  a  softening  all  through  its  tissue,  extending  up 
to  the  globular  capsule  of  muscular  fibre  which  contains  the 
foetus.  The  lower  portions  of  the  uterus  move  in  harmony 
with  the  fundus.  The  other  well-known  signs  of  pregnancy 
will,  of  course,  be  looked  for. 

Hydramnios.  Dropsy  of  the  Amnion. — In  pregnancy  compli- 
cated with  albuminuria  the  amniotic  fluid  may  be  in  excess, 
giving  rise  to  a  condition  that  may  be  not  unlike  ovarian  or 
parovarian  cyst.  The  uterine  walls  are  very  thin,  and  fluc- 
tuation may  readily  be  elicited,  while  the  foetus  may  be  beyond 


SCHEMATIC  ARRANGEMENT  OF  TUMOURS.  41 

the  reach  of  palpation.  Special  weight  is  to  be  given  to  the 
condition  of  the  cervix — softened,  as  in  ordinary  pregnancy, — 
and  to  the  other  evidences  of  gestation. 

Hamatometra. — A  round  globular  collection  of  fluid  in  the 
lower  abdomen  and  pelvis  of  a  young  woman  who  has  not 
menstruated,  but  who  has  passed  the  period  of  puberty,  may  be 
a  collection  of  blood  inside  the  uterus.  The  cervix  uteri  is  not 
softened  nor  swollen,  and  there  are  no  signs  of  pregnancy.  The 
amount  of  cervical  tissue  felt  will  depend  on  whether  the  atresia 
is  at  the  external  or  the  internal  os.  Sometimes  there  is  complete 
atresia  of  the  vagina,  which  in  itself  suggests  the  diagnosis. 

HtBmatokolpos.  Retained  Menses. — The  various  conditions  in 
the  vagina  or  hymen  which  prevent  the  outflow  of  the  menstrual 
fluid  at  puberty  may  cause  the  appearance  of  a  cystic  tumour 
in  the  lower  abdomen.  The  ordinary  sign  of  a  fluid  encysted 
enlargement,  with  the  abnormality  easily  discovered  by  vaginal 
examination,  in  addition  to  amenorrhoea,  will  make  the  diagnosis 
easy.  Haematokolpos  bulges  more  into  the  pelvis  than  haemato- 
metra  ;  it  may  even  cause  distension  of  the  perineum,  and  visibly 
protrude  through  the  vulva.  The  uterus  sessile  on  the  top  of 
the  cyst  may  sometimes  be  palpated  through  the  abdomen. 

Hydrometra. — When  occlusion  of  the  cervical  canal  at  its 
external  or  internal  opening  takes  place  after  the  menopause, 
there  is  a  collection  of  fluid  in  the  uterus  that  is  not  blood, 
but  a  clear  or  blood-stained  watery  or  viscid  fluid.  The  uterine 
walls  are  much  attenuated,  and  fluctuation  is  well  marked.  As 
a  clinical  curiosity,  an  hour-glass  dilatation  of  the  uterus,  from 
occlusion  of  the  external  as  well  as  the  internal  os,  may  be 
mentioned.  Such  collections  of  watery  fluid  inside  the  uterus 
do  not  usually  attain  to  large  size,  and  they  are  of  very  slow 
growth.  If,  as  very  rarely  happens,  the  contents  suppurate,  we 
get  the  condition  cdMed  pyometva. 

Extra-idevine  Pregnancy. — While  the  fcetus  is  still  alive,  and 
the  fluids  are  in  normal  amount,  an  extra-uterine  gestation  may 
appear  in  the  lower  abdomen  as  a  thin-walled  obscurely  fluc- 
tuating cyst,  with  firm  and  deep  connections  in  the  pelvis.  By 
the  vagina,  an  enlarged  and  probably  anteverted  uterus,  inti- 


42  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

mately  connected  with  the  growth,  will  be  detected.  General 
matting  and  induration  in  Douglas's  pouch,  and,  very  likely, 
part  of  the  contour  of  a  foetus,  may  be  felt.  The  signs  of  preg- 
nancy, modified  and  misleading,  will  be  present. 

Cysts  of  the  Urachns. — Small  cysts  of  the  urachus  containing 
a  few  drachms  of  fluid  are  sometimes  found  at  abdominal 
operations.  Large  cysts  are  rare.  They  are  exactly  median, 
rise  a  little  higher  than  ovarian  tumours  of  the  same  size,  have 
no  connection  with  the  uterus,  and,  if  not  large,  may  leave  a 
resonant  area  between  their  lower  margins  and  the  pubes. 
They  fluctuate  freely  in  all  directions.  Sometimes  there  is  a 
history  of  urinary  trouble. 


FLUID  NON-SYMMETRICAL  TUMOURS  FOUND  ON  EITHER  STDE  OF 
THE  ABDOMEN. 

Fhiid  Enlargements  connected  with  the  Kidney. — These  are  : 

Renal  cysts, 
Hydatids, 
Hydro-nephrosis, 
Pyo-nephrosis. 

The  special  diagnosis  of  these  conditions  must  be  carried 
out  by  methods  other  than  the  purely  physical.  Certain  phy- 
sical signs  which  they  have  in  common  may  here  be  enumerated. 
A  cystic  enlargement  of  the  kidney  lies  in  close  contact  with 
the  parietes  in  the  lumbar  region,  causing  absolute  dulness 
there  and,  according  to  its  size,  over  the  anterior  surface ;  and 
is  either  fixed  or  but  slightly  movable,  having  its  main  attach- 
ment deep  in  the  loin.  Growing  from  the  side  towards  the 
middle  line,  as  well  as  upwards  and  downwards,  it  may  occupy 
the  whole  abdominal  cavity.  But  it  nearly  always  leaves  reso- 
nance in  the  opposite  flank,  and  can  rarely  be  detected  by 
vaginal  palpation.  The  passage  of  colon  over  it  may  be  re- 
vealed by  percussion  and  palpation. 

Nephric  and  Peri-nephric  Abscess. — A  collection  of  fluid  in  the 
region  of  the  kidney,  associated  with  signs  of  suppuration,  may 


SCHEMATIC   ARRANGEMENT  OF  TUMOURS.  43 

be  abscess  in  the  organ  itself  or  in  the  outlying  tissues.  It  is 
not  always  possible  to  differentiate  the  two  conditions ;  in  fact, 
they  are  often  associated.  In  cases  of  any  standing  there  is 
discolouration  of  the  overlying  skin,  with  inflammatory  thick- 
ening in  the  deep  parts,  and  tenderness  on  pressure.  The  lum- 
bar muscles  are  fixed,  tense  and  brawny.  Positive  signs  of  fluid 
are  frequently  absent :  in  most  cases  the  early  condition  of  renal 
suppuration  is  that  of  a  solid,  and  not  of  a  fluid,  enlargement. 

Fluid  Collections  in  the  Fallopian  Tubes. — These  are : 
Hydro-salpinx, 
Haemato-salpinx. 
Pyo-salpinx. 

It  is  not  often  that  cystic  enlargements  of  the  Fallopian 
tubes  become  abdominal  tumours.  They  are  usually  confined 
to  the  pelvis,  and  discovered  by  vaginal  and  rectal  palpation, 
or  by  the  ordinary  bimanual  method.  An  ovoid  or  irregular 
fluid  collection  of  small  size  lying  in  the  retro-uterine  space, 
and  usually  on  one  side  of  it,  may  be  a  cystic  dilatation  of  the 
Fallopian  tube.  It  is  evidently  closely  connected  with  one  side 
of  the  uterus  at  the  fundus.  If  painless,  it  is  possibly  hydro- 
salpinx ;  but  this  cannot  be  differentiated  from  small  cysts  of 
the  ovary.  If  painful  on  palpation  — and  pain  is  often  a  very 
prominent  symptom — it  is  probably  pyo-  or  haemato-salpinx  ; 
but  may  be  ovarian  abscess,  or  localised  pelvic  suppuration, 
either  primary  or  resulting  from  pelvic  haematocele.  The  diag- 
nosis of  lesions  of  the  Fallopian  tubes  is  attended  with  con- 
siderable difficulty. 

Extra-uterine  Pregnancy,  and  especially  Fallopian  pregnancy 
(which  all  these  cases  probably  are),  is,  in  its  early  stages, 
unilateral,  and  is  obscurely  cystic.  When  rupture  takes  place, 
the  enlargement  is  chiefly  median. 

Ovarian  Abscess. — A  suppurating  ovary  is  usually  dislocated 
downwards.  It  is  rarely  larger  than  a  hen's  egg,  very  tender  on 
pressure,  tense  and  obscurely  fluctuating.  It  usually  Hes  in  the 
recto-uterine  pouch,  on  one  side  or  the  other,  and  cannot,  on 
account  of  adhesions,  be  moved  from  this  situation. 


44  DIAGNOSIS  OF  ABDOMINAL    TUMOURS. 


FLUID  NON-SYMMETRICAL  TUMOURS  ON  THE  RIGHT  SIDE  OF  THE 

ABDOMEN. 

Abscess  of  the  Liver. — Only  in  its  later  stages  can  the  presence 
of  fluid  in  a  hepatic  abscess  be  detected  by  palpation.  There 
is  general  enlargement  of  the  area  of  hepatic  dulness  ;  the  liver 
margin  can  be  palpated  under  the  ribs,  and  pressure  there 
causes  pain  ;  there  are  the  usual  signs,  not  always  well  marked, 
however,  of  suppuration  ;  and  in  advanced  cases,  where  the 
growth  of  the  abscess  is  mainly  downwards,  there  may  be  a 
palpable  and  visible  protrusion  of  the  parietes.  Exploratory 
puncture  reveals  the  presence  of  pus. 

Hydatid  Disease  of  the  Liver. — A  hydatid  cyst  usually  appears 
as  a  smooth,  painless  globular  enlargement  in  the  right  hypo- 
chondriac or  epigastric  regions,  obscurely  fluctuating,  elastic 
and  resisting.  The  characteristic  hydatid  fremitus  is  not  always 
detected.  If  the  cyst  lies  deep  in  the  hepatic  tissue,  or  on  its 
posterior  aspect,  it  produces  no  signs  other  than  hepatic  en- 
largement. Exploratory  puncture  reveals  the  existence  of  clear 
hydatid  fluid,  perhaps  with  portions  of  the  entozoa.  Hydatid 
cysts  sometimes  suppurate,  and  then  are  indistinguishable  from 
abscess. 

Distension  of  the  Gall-hladder'.^-K  pyriform  or  ovoid  cystic 
swelling  in  the  right  hypochondrium,  fixed  under  the  liver, 
but  movable  elsewhere,  painless  or  but  slightly  painful,  will 
probably  be  distended  gall-bladder.  The  exact  nature  of  its 
contents — watery,  or  purulent,  or  bilious — will  be  revealed  by 
the  consideration  of  accessory  symptoms. 


FLUID     NON-SYMMETRICAL     ENLARGMENTS     ON     THE     LEFT    SIDE    OF 

THE    ABDOMEN. 

Splenic  Abscess. — Abscess  of  the  spleen  is  of  rare  occurrence; 
and,  unless  it  is  of  large  size,  and  shows  a  tendency  to  burst 
through  the  parietes,  it  is  not  often  diagnosed.  Fluctuation  is 
always  obscure,  often  unrecognisable.  Though  the  symptoms 
are  usually  acute  and  attended  with  pain,  they  are  sometimes 


SCHEMATIC   ARRANGEMENT  OF  TUMOURS.  45 

very  chronic,  and  little  more  may  appear  in  evidence  of  splenic 
abscess  than  a  boggy  semi-elastic  tumour  in  the  left  hypo- 
chondrium.  I  have  seen  a  case,  in  the  practice  of  a  colleague, 
where  a  large  abscess  of  the  spleen  was  opened  and  a  piece  of 
sloughed  splenic  tissue  removed,  nearly  as  large  as  an  orange, 
which  showed  slight  and  unimportant  signs  of  its  presence. 

Hydatids  of  the  Spleen. — This  condition  is  also  rare.  A  pain- 
less tumour  in  the  region  of  the  spleen,  smooth  on  the  surface, 
but  sometimes  lobulated,  obscurely  fluctuating  or  only  bogg)^, 
painless,  and  perhaps  exhibiting  the  hydatid  trembling,  is 
probably  hydatid  cyst  of  the  spleen.  Exploratory  puncture 
renders  the  diagnosis  certain. 


Artificial  Distension  of  the  Stomach  and  Intestines 
as  an  aid  to  Diagnosis. 

Distension  of  the  stomach  and  the  intestines  by  gas  and  by 
fluids  has  recently  been  advocated  and  employed  in  the  diag- 
nosis of  abdominal  diseases  and  injuries.  Senn  of  Milwaukee 
has  recently  employed  rectal  and  stomachic  inflation  of  hydrogen 
gas  for  the  purpose  of  diagnosing  perforation  of  the  viscera, 
and  others  have  followed  his  example.  This  will  be  again 
referred  to.  In  1883  Ziemmsen  used  inflation  of  the  rectum  with 
carbonic  acid  gas  as  an  aid  to  diagnosis,  and  spoke  highly  of 
the  plan,  but  it  did  not  come  into  extensive  use.  More  recently 
Minkowski*  has  made  an  elaborate  study  of  the  practice  in 
aiding  the  diagnosis  of  abdominal  tumours,  having  employed  it 
in  no  fewer  than  no  cases.  He  distended  the  stomach  with 
carbonic  acid  gas  generated  by  the  administration  of  bicarbonate 
of  soda  and  tartaric  acid  ;  water  was  employed  for  distending  the 
rectum.  A  comparison  of  the  position  and  relations  of  the  tumour 
before  and  after  distension  reveals  certain  facts  which  may  be  of 
importance.  Tumours  of  the  liver,  gall-bladder,  and  spleen  are 
displaced  or  more  distinctly  outlined  after  gaseous  distension  of 
the  stomach.  The  diagnosis  of  tumours  of  the  large  intestine, 
mesentery,  kidney,  and  pancreas  is  said  to  be  assisted  by  fluid 
*  Berl.  Klin.  Woch.  No.  31,  1868. 


46  DIAGNOSIS  OF  ABDOMINAL    TUMOURS. 

injections  into  the  large  intestine.  The  inferences  as  to  changes 
in  position  or  variations  in  dulness  are  to  be  made  from  known 
anatomical  relations,  and  need  not  here  be  enlarged  upon. 

As  a  routine  method  of  aiding  in  the  diagnosis  of  abdominal 
tumours,  artificial  distension  of  the  hollow  viscera  has  not  found 
much  favour  in  this  country.  In  the  great  majority  of  cases  it 
is  superfluous ;  in  such  cases,  its  employment  is  barbarous  in  the 
same' sense  that  it  is  barbarous  to  seek  to  elicit  crepitus  in  a 
case  of  fracture  where  other  symptoms  suffice  for  diagnosis.  In 
many  cases  it  is  inadmissible :  the  condition  of  the  patient 
forbids  the  deliberate  infliction  of  pain,  or  even  discomfort,  for  a 
possible  but  doubtful  help  in  diagnosis.  Where  the  patient's 
condition  admits  of  it ;  where  diagnosis  is  incomplete,  and  is 
likely  to  be  made  more  complete  by  the  proceeding,  we  may,  if 
it  is  important  that  the  diagnosis  be  made,  employ  it. 


General  Examination  of  the  Patient. 

What  has  been  said  refers  merely  to  the  diagnosis  of  the 
growth  or  disease  for  which  operation  is  contemplated.  But 
before  such  operation  is  decided  upon,  we  must  also  make  an 
investigation  of  every  vital  organ — diagnose  the  condition  of 
the  patient,  in  fact.  The  importance  of  this  cannot  be  too 
strongly  insisted  upon.  Many  of  the  catastrophes  of  abdominal 
surgery  are  to  be  attributed  to  overlooking  some  lesion  of  an 
important  organ,  such  as  an  exhaustive  and  skilful  investigation 
of  the  whole  of  the  system  might  have  detected.  The  grand 
fact  of  the  diagnosis  of  the  tumour,  and  everything  connected 
with  it,  is  too  apt  to  overshadow  the  diagnosis  of  other  things. 
We  take  a  pride,  and  justly,  in  the  rapidity  and  accuracy  with 
which  we  can  diagnose  the  nature  and  connections  of  an 
abdominal  tumour;  and  this  cultured  and  impressive  skill  is 
liable  to  make  us  impatient  of  the  tedious  medical  examination 
of  the  whole  system.  The  condition  of  the  heart,  lungs,  kid- 
neys, no  one  would  dare  to  overlook  who  was  not  recklessly 
foolish  ;  but  any  abnormal  symptom,  howevef  apparently  trivial, 


SCHEMATIC   ARRANGEMENT  OF   TUMOURS.  47 

ought  to  be  followed  up  to  its  origin.  For  instance,  in  two 
cases  of  abdominal  tumour,  I  had  seen  bleeding  from  the 
rectum,  as  an  effect  of  pressure,  which  disappeared  when  the 
growth  was  removed.  A  third  case  had  similar  bleeding,  but 
for  certain  reasons  was  not  at  once  submitted  to  operation. 
Later  on,  the  continuance  of  the  bleeding  demanded  a  special 
examination,  and  revealed  cancer  of  the  rectum.  Had  I  oper- 
ated upon  this  patient  when  she  was  first  seen,  I  should  have 
done  so  in  ignorance  of  this  condition.  Dr.  Henry  C.  Coe*-' 
records  a  case  which  he  lost  from  having  overlooked  a  stricture 
of  the  colon;  and  many  other  similar  cases  could  be  quoted. 
Therefore,  we  ought  never  lightly  to  pass  over  a  symptom  that 
might  be  caused  by  the  disease :  we  ought  to  be  certain  before 
operating  that  the  symptom  is  so  caused. 


Exploratory  Incision. 

There  is  no  doubt  that  a  good  deal  of  rashness  and  a  certain 
amount  of  incompetence  is  sought  to  be  concealed  by  the  prac- 
tice of  "exploratory  incisions."  No  incision  ought  to  be  merely 
exploratory :  at  the  utmost,  it  ought  to  be  ultimately  diagnostic 
in  a  case  of  extreme  doubt  and  difficulty.  The  exploratory 
incision  of  the  skilled  surgeon  is  Avidely  different  from  that  of 
the  tyro.  Where  the  former  will  make  a  correct  diagnosis  in 
ninety-nine  out  of  a  hundred  cases,  the  latter  will  fail  over  his 
tenth  case ;  but  he  may  not  conclude  that  the  justification  of 
exploratory  operation  is  assured  merely  because  he  is  in  doubt  in 
this  case.  Perhaps  surgeons  of  large  experience  are  somewhat  to 
blame  for  so  freely  speaking  of  this  tentative  proceeding  as  being 
frequently  justifiable  and  necessary.  What  is  justifiable  in  their 
experienced  hands,  may  not  be  so  in  the  hands  of  less  experienced 
men.  Before  submitting  our  patient  to  what,  after  all,  is  a  serious 
operation  and  a  trying  illness,  we  ought  again  and  again  to 
return  to  the  examination  of  the  disease,  read  and  re-read  the 
exhaustive  history,  and  decide  only  after  having  done  this.  At 
*  N.   Y.  Med.  Journ,,  May  9th,   1SS5. 


48  DIAGNOSIS   OF  ABDOMINAL   TUMOURS. 

different  examinations  the  mind  focuses  its  attention  on  different 
points,  and  travels  in  different  directions  ;  and  each  examination 
may  give  us  new  information.  The  help  of  a  skilled  friend  is 
always  valuable,  but  too  much  weight  must  not  be  given  to  it. 
Responsibility  begets  trustworthiness :  the  man  who  operates  is 
the  man  who  must  diagnose,  and  additional  acumen  is  given  to 
his  powers  by  the  heavy  responsibility  that  waits  upon  their 
fruition. 

Having  made  this  "  exploratory  incision,"  we  must  not  be 
too  rash  in  converting  it  into  an  operative  one.  We  ought  to 
be  sure,  before  inflicting  the  slightest  injury  upon  the  growth, 
that  we  can  remove  it.  To  have  been  forced  to  submit  the 
patient  to  exploration  by  incision,  is  grievous  enough  ;  but  to 
have  added  thereto  additional  risks  from  sheer  meddlesome- 
ness, is  unpardonable.  Difficulties  and  dangers,  legitimate  and 
unavoidable,  are  numerous  enough,  in  all  conscience,  in  abdom- 
inal surgery :  let  us  not  to  these  add  risks  that  are  illegitimate 
and  avoidable. 


Section   II 


ABDOMINAL     OPERATIONS     CONSIDERED 
GENERALLY. 


Nomenclature.    Historical. 

The  operation  of  abdominal  section  has  for  a  very  long 
time  been  known  by  the  term  Gastrotomy,  from  '/rto-T*)/)— belly, 
and  To/ni'j — incision.  As  the  proceeding  was  at  first  carried  out 
only  for  the  purpose  of  removing  a  foetus  from  the  womb,  the 
name  came  to  have  a  limited  application  to  Caesarean  section. 
Thus,  in  the  dictionar}^  by  Blancard  of  Middleburg,  in  Zealand, 
published  near  the  end  of  the  seventeenth  century,  and  trans- 
lated into  English  in  1702,  "  Gastrotomia  "  is  defined  as  "  the 
cutting  open  of  the  abdomen  and  womb,  as  in  sectio  Caesarea." 
Gastrorraphy  about  this  time  was  chiefly  used  as  meaning 
simple    suture  of  wounds  in  the  abdomen ;    but    it  was   also 

5 


50  NOMENCLATURE. 

applied  to  the  introduction  of  sutures  in  the  bowel.  In  these 
instances  the  word  ya<r7r]p  was  used  in  its  original  and  legitimate 
sense,  corresponding  to  the  vulgar  rather  than  the  anatomical 
word  "  stomach ; "  but  when  the  stomach  proper  came  within 
the  sphere  of  practical  surgery,  Gastrotomy  was  often  used  for 
the  operation  of  removal  of  foreign  bodies  from  that  viscus. 
Sedillot  introduced  the  word  Gastrostomy  {aro/na — mouth)  to 
indicate  the  formation  of  stomachic  fistula ;  and  Gastrorraphy 
has  quite  recently  been  used  by  Billroth  and  others  to  signify 
closure  of  an  opening  in  the  stomach  by  suture.  In  the  begin- 
ning of  this  century  the  term  Laparotomy  {Xmrapa — flank)  came 
into  use  for  operations  such  as  herniotomy,  or  the  operation  for 
artificial  anus  made  in  the  loin.  Soon  it  came  to  have  a  wider 
significance,  and  now  it  is  applied  to  any  and  every  operation 
in  which  section  of  the  abdominal  walls  is  performed.  As,  in 
the  words  Gastrostomy,  Gastrotom}^,  Gastrorraphy,  ^/affn'jp  is 
probably  now  permanently  appropriated  to  the  anatomical 
stomach.  Laparotomy  is  probabl}^  the  best  word  to  use  generally 
for  the  operation  of  abdominal  section.  "  Ventrotomy "  has 
recently  been  proposed  as  a  convenient  term  for  abdominal 
section.  Unfortunately,  there  is  abundant  precedent  for  the 
introduction  of  barbarous  words  into  our  terminology;  but  the 
practice  scarcely  deserves  encouragement.  Petit"^-'  would  limit 
the  word  Gastrotomy  to  indicate  in  a  general  way  the  operations 
practised  on  the  abdominal  wall ;  Laparotomy,  for  the  oper- 
ations performed  for  intestinal  obstruction ;  and  Stomachic 
Incision  (Taille  stomacale),  for  removal  of  foreign  bodies  from 
the  stomach.  But  abdominal  terminology  in  England  has 
already-  got  beyond  the  possibility  of  using  these  limitations. 
The  special  operation  is  sought  to  be  indicated  by  affixing 
certain  terminal  words  to  the  Greek  name  of  the  organ  indi- 
cated. Thus,  "-tomy"  (to/o) — incision)  is  added  to  indicate 
mere  incision,  as  in  nephrotomy,  hepatotomy,  cholecystotomy. 
The  termination  " -ectomy  "  (eV,  out  of;  to/u})  is  added  to  indi- 
cate cutting  out  or  removing  the  organ  ;  as  in  nephrectomy, 
splenectomy,  colectom}^  pylorectomy,  &c.  The  suffix  "-stomy" 
*  Diet.  Encycl.  dcs  Sc.  Med.,  tome  VII.,  1881,  art.  "  Gastrotomie." 


NOMENCLATURE.  51 

{oTofjia — mouth)  indicates  the  formation  of  an  opening  in  a 
hollow  viscus  that  is  intended  to  be  permanent ;  as  in  gastro- 
stomy, gastro-enterostomy.  In  colotomy,  an  opening  is  made 
that  is  usually  permanent,  and  the  word  colostomy  would  then 
be  more  exact ;  enterotomy  would  sometimes,  but  not  always, 
be  better  indicated  by  the  word  enterostomy.  The  termination 
"-rraphy"  or  "-rhaphy"  {^a(f)i) — suture)  is  used  as  meaning  any 
suturing  of  an  organ  for  wound,  as  gastrorraphy ;  or  to  fix  it,  if 
movable,  as  nephrorraphy.  The  latter  term  might  also  be  very 
properly  used  to  indicate  the  suturing  of  a  wound  or  laceration 
of  the  kidney. 

The  history  of  each  operation  will  be  given  in  its  proper  place. 
Here  it  need  only  be  noted  that  the  progress  of  abdominal 
surgery  has  not  been  simply  forward  in  a  straight  line,  but  in 
waves  of  advancement  and  retrogression.  There  can  be  no 
doubt  that  the  technique  of  abdominal  surgery  was  more  perfect 
nearly  two  centuries  ago  than  it  was  fifty  j^ears  ago.  Minute 
and  excellent  directions  for  making  and  for  suturing  wounds  in 
the  abdominal  walls  were  given  in  several  works  on  surgery 
published  during  the  seventeenth  and  eighteenth  centuries.  In 
more  than  one  of  the  works  of  this  period  instructions  as  to  the 
inclusion  of  the  peritoneum  in  suturing  the  abdomen  are  given 
with  scientific  precision.  Heister,  who  wrote  about  the  middle 
of  the  eighteenth  century,  so  far  anticipated  modern  art  as  to 
advocate  drainage  of  the  lower  abdomen  by  a  cannula,  and 
washing  it  out  by  "  vulnerary  decoctions."  In  Cagsarean  sec- 
tion, Roussetus  advised  this,  as  well  as  drainage  of  the  uterus 
by  a  cannula  inserted  into  its  cavity.  The  directions  given  for 
closing  an  abdominal  wound  by  Dionis,  in  his  Course  of  Surgical 
Operations  (1733),  might  almost  be  quoted  bodily  as  the  practice 
of  the  Samaritan  Free  Hospital  to-day. 

All  this  good  work  was  ignored,  and  more  which  followed  it ; 
and,  in  times  comparatively  modern,  much  good  practice  that 
had  been  tried  and  proved  by  past  masters  in  the  art  was 
neglected  and  overlooked.  The  clamp  in  ovariotomy  was  a  dis- 
tinct step  backward;  but  the  amount  of  advance  which  followed 
its  abolition,  being  synchronous  with  the  introduction  of  anti- 

5  * 


52  OPERATIVE  SURGERY  OF  ABDOMEN. 

septics,  cannot  accurately  be  estimated.  I  think  there  can  be 
no  doubt  that  the  most  important  single  contribution  to 
abdominal  surgery  is  the  gospel  of  surgical  cleanliness  preached 
by  Lister;  but  along  with  this  we  must  reckon  the  greater 
perfection  of  finish  in  every  operation,  rendering  the  work 
of  the  best  operators  something  approaching  the  ideal  in 
surgical   art. 

The  Operative  Surgery  of  the  Abdomen. 

The  practical  surgery  of  the  abdomen  presents  many 
features  special  to  itself.  The  manipulations  have  to  be 
performed  in  an  area  exquisitely  sensitive  to  traumatic  in- 
fluences, and  in  the  midst  of  organs  whose  integrity  is 
peculiarly  necessary  to  life.  The  peritoneal  fluids  are  very 
prone  to  take  on  septic  contamination,  and  the  inflammation 
thereby  induced  is  doubly  dangerous,  from  the  great  amount  of 
surface  over  which  it  may  extend,  and  from  the  involvement 
of  the  structures  of  the  sympathetic  system,  which  are  so 
abundantly  distributed  under  the  peritoneal  membranes. 

Before  an  abdominal  operation  can  be  performed  section 
of  the  parietes — a  proceeding,  in  itself  demanding  some  surgical 
skill  and  knowledge — has  to  be  concluded ;  and,  when  the 
operation  proper  is  finished,  the  accurate  closure  of  this  wound, 
in  a  manner  fully  to  meet  the  immediate  and  remote  demands 
made  upon  its  union,  requires  more  care  than  does  an  ordinary 
surgical  wound.  The  manipulations  in  the  cavity  have  to  be 
performed  frequently  at  some  distance  from  the  surface,  some- 
times out  of  sight,  and  are  often  of  a  difficult  and  delicate 
nature.  Through  the  whole  proceeding,  careful  avoidance  of 
injury  to  vulnerable  organs  by  rough  handling  or  exposure,  and 
minute  and  continuous  attention  to  secure  absolute  cleanliness 
in  hands,  instruments,  and  sponges,  are  especially  important. 
Lastly,  certain  well-established  rules  as  to  the  environment  of 
the  patient,  and  the  management  of  the  case,  must  be  attended 
to.  These  and  such  questions,  being  common  to  all  abdominal 
operations,  will  now  be  considered  in  detail. 


THE  SICK-ROOM.  53 

ENVIRONMENT    OF    PATIENT. 

The  Sick-room. — There  is  no  disputing  the  fact  that  the 
best  results  in  abdominal  surgery  are  got  in  specially  prepared 
rooms  or  wards.  It  is  true  also  that  the  mortality  in  large  general 
hospitals  is  greater  than  in  small  specially  designed  hospitals. 
But  it  is  further  a  fact  that  the  most  experienced  operators  are 
attached  to  the  small  special  hospitals ;  and  it  is  therefore 
impossible  to  say  how  far  the  good  results  are  to  be  attributed 
to  the  surroundings  of  the  patient,  and  how  far  to  the  skill  of 
the  surgeon.  That  an  a  priori  probability  of  the  greatest  success 
would  be  got  in  specially  designed  hospitals,  fully  under  the 
control  of  a  highly  skilled  surgeon,  there  is  no  question  ;  and 
this  would  hold  true  of  any  surgical  operation  in  the  hands  of  a 
man  who  specially  devoted  himself  to  it.  But,  at  the  present 
time  at  least,  it  is  perhaps  nearl}?-  as  true  of  abdominal  as  of 
other  operations,  that  extra  care  in  avoiding  all  matters  con- 
ducive to  septicism  will,  with  surroundings  such  as  most 
surgeons  can  command,  justify  their  being  carried  out  either 
in  general  hospitals  or  in  private  dwellings.  Very  few  surgeons 
can  begin  an  operation  of  any  sort  with  the  consciousness  that 
the  patient  is  being  submitted  to  the  best  conceivable  conditions 
for  recovery :  much  that  is  justifiable  is  not  perfect. 

This,  of  course,  is  no  argument  against  every  effort  being 
made  to  secure  for  the  patient  the  best  possible  surroundings. 
An  ideal  room — situated  in  an  open  and  elevated  locality 
ventilated  with  warmed  (and  perhaps  filtered)  air,  wall  and 
floor  impermeable  to  moisture  and  readily  and  easily  washed, 
and  with  many  other  excellences  which  could  be  detailed — is 
rarely  in  this  country  at  the  disposal  of  surgeons.  Such  rooms, 
abundant  enough  in  America  and  on  the  Continent,  are  usually 
erected  at  the  private  expense  of  the  operators.  In  only  a  few 
hospitals  in  England  are  there  specially  prepared  private  wards 
for  abdominal  surger}^ 

If  the  operation  has  to  be  performed  in  a  private  dwelling,  a 
large,  bright  room  with  a  southern  aspect,  and  which  can  be 
kept    comfortably   warmed   and   well   ventilated,    ought    to   be 


54  OPERATIVE  SURGERY  OF  ABDOMEN. 

selected.  A  room  that  has  not  been  constantly  occupied  as  a 
bedroom  is  likely  to  be  more  fresh  and  sweet  than  one  that  has 
been  so  occupied.  Carpets,  curtains,  and  everything  that  may 
harbour  dust  and  filth,  ought  to  be  removed.  A  well-kept 
bedroom,  in  a  home  of  gentlefolks,  will  require  nothing  changed 
or  removed. 

If  the  windov/s  are  kept  open  for  twenty-four  hours  or  so, 
while  a  large  fire  is  kept  burning  in  the  grate,  the  room  will  be 
freshened  and  purified,  and  thus  made,  not  only  a  more  pleasant, 
but  a  more  safe  habitation  for  the  patient. 

Admission  of  Visitors. — The  question  of  the  presence  of 
visitors  at  the  operation  has  been  much  discussed.  Some 
surgeons  admit  no  visitors  beyond  their  immediate  assistants ; 
others  admit  a  limited  number,  who  declare  that  they  have  not 
recently  been  in  contact  with  septic  products ;  not  many  admit 
visitors  without  restriction  of  any  sort.  If  the  room  is  small, 
one  would  certainly  rather  not  have  the  air  made  foul  by 
crowding  ;  and  in  every  case,  one  would  not  care  to  have  in  the 
room  individuals  who  have  recently  come  from  contact  with 
cases  of  pyaemia  or  erysipelas.  But  if  one  has  full  confidence 
in  the  antiseptic  spray,  and  the  room  is  large,  I  see  little 
necessity  in  being  particular  as  to  the  admission  of  onlookers, 
wherever  they  may  have  come  from,  and  whatever  be  their 
number.  In  the  Bristol  Infirmary,  I  operate  in  the  general 
theatre,  placing  no  restrictions  whatever  on  visitors  ;  and  it 
happens,  by  a  somewhat  clumsy  arrangement,  that  the  adminis- 
trator of  anaesthetics  is  also  the  pathologist.  The  results,  over 
more  than  eighty  cases  (I  purposely  exclude  private  operations), 
are  equal  to  those  got  in  any  special  hospital. 

Purification  of  Atmosphere. — Some  surgeons  seek  to  improve 
the  purity  of  the  atmosphere  in  which  the  operation  is  to  be 
performed  by  making  a  steam  antiseptic  spray  play  in  the  room 
for  a  few  hours.  There  is  no  strong  objection  to  this  :  if  it  does 
nothing  else,  it  lays  the  dust.  But  if  the  room  has  been  properly 
cleansed  and  ventilated,  and  the  surrounding  air  is  of  the 
moderate  purity  and  freshness  that  may  be  found  almost  any- 
where in  England,  the  spray  in  the  room  is  perhaps  uncalled 


NURSING.  00 

for.  If  an}'  objection  could  be  raised  to  the  proceeding,  I  think 
it  ought  to  be  on  the  ground  of  saturating  the  atmosphere  with 
moisture.  Respiration  is  not  so  easy  in  an  atmosphere  laden 
with  moisture,  as  in  one  that  is  dry ;  and  if  a  patient  has  to 
undergo  a  prolonged  and  dangerous  operation,  we  should  desire 
to  have  the  recovery  from  shock  promoted  by  every  possible 
surrounding  benefit — one  of  which  is  certainly  not  a  wet, 
depressing  atmosphere  to  breathe. 

As  to  the  beds  and  bedding,  no  special  directions  need  be 
given.  A  narrow  bed,  preferably  with  spring  or  woven-wire 
bottom,  on  which  is  laid  a  good  horsehair  mattress,  will  satisfy 
all  requirements.  I  prefer  to  have  two  beds  ;  the  patient  being 
lifted,  in  the  sheet  on  which  she  lies,  from  one  bed  to  the  other 
every  night  or  morning,  or  both  night  and  morning,  and  the 
unused  mattress  being  taken  out  of  the  room  to  be  dried  and 
aired.     This,  however,  is  a  luxury,  and  not  a  necessity. 

For  clothing,  I  think  the  best  plan  is  to  entirely  discard  the 
night-dress,  and  use  instead  a  jacket,  made  of  fine  flannel, 
which  reaches  as  far  as  the  loins.  If  the  patient  desires  it,  linen 
drawers  may  be  worn.  Free  access  to  every  part  of  the  abdo- 
men, with  warmth  and  lightness,  are  the  chief  requisites  in  the 
clothing  of  such  patients. 

The  Nuyse. — For  nursing  abdominal  cases,  no  special  skill  is 
necessary  in  the  attendant  beyond  ability  to  pass  the  catheter 
with  gentleness  and  dexterity,  and  v/ithout  moving  or  exposing 
the  patient.  Clumsiness  in  this  art  worries  the  patient  to  an  un- 
necessary degree  :  and  this  worry  the  surgeon  may  know  nothing 
of,  as  the  patient  believes  it  to  be  a  necessary  part  of  the  treat; 
ment,  and  does  not  complain ;  while  the  nurse  is  not  likely  to 
speak  of  her  own  awkwardness.  It  is  extraordinary  how  rarely 
we  find  even  the  most  skilled  nurse  able  to  catheterise  a  patient 
secundum  artem.  It  will,  therefore,  be  well  to  see  the  nurse  pass 
the  catheter  at  least  once  on  each  new  patient.  If  she  fails  in 
dexterity,  a  hint  as  to  any  peculiarity  of  conformation,  and  the 
way  to  overcome  it,  will  give  her  confidence  in  future  acts  of 
catheterisation.  Beyond  this,  the  nurse  must  have  a  perfect 
familiarity  with  the  use  of  the  rectum  tube,  which  may  be  left  to 


56  OPERATIVE   SURGERY  OF  ABDOMEN. 

her  discretion  ;  and  a  practical  knowledge  in  the  administration 
of  enemas.  A  perfect  nurse  is  a  perfect  woman,  rarely  to  be 
had ;  but  good  temper,  implicit  and  uncomplaining  obedience, 
gentleness,  cleanliness,  and  some  degree  of  physical  strength 
and  endurance,  are  absolutely  essential. 

In  simple  cases,  one  nurse  will  be  sufficient,  as  after  the  first 
few  days  she  may  have  full  rest.  In  bad  cases,  it  is  wise  to 
have  a  day  and  a  night  nurse.  Not  only  will  they  give  better 
nursing,  but  they  will  give  some  variety  to  the  patient,  and  be 
more  bright  and  cheerful  in  the  sick-room  than  if  they  were 
tired  and  over-worked. 

PRELIMINARIES    TO    OPERATION. 

Preparation  of  Patient. — In  most  cases,  all  that  is  wanted  by 
way  of  preparation  is  the  administration  of  a  purge  the  day 
before  operation — supplemented,  where  deemed  expedient,  by  a 
simple  enema.  The  last  two  or  three  meals  should  be  of  suclr 
a  nature  that  no  residue  will  be  left  in  the  bowel  at  the  time  of 
operation.  If  peritonitis  or  enteritis  supervene,  it  will  be  one 
point  in  favour  of  good  progress  that  there  are  no  irritating 
matters  in  the  bowel.  Starvation  for  two  or  three  days  before 
operation,  as  has  been  recommended,  is  unnecessary  and 
detrimental.  The  advantage  of  having  to  operate  with  collapsed 
bowel  inside  the  abdomen  is  more  than  counterbalanced  by  the 
weakening  of  the  patient  which  such  a  procedure  induces. 

I  think  that  the  advantages  of  catheterism  before  operation 
are  somewhat  exaggerated.  I  am  convinced  that  it  is  unneces- 
sary, and  I  never  have  it  done.  The  patient  may  pass  water 
before  operation :  if  there  is  some  abnormal  condition  in  the 
bladder  which  prevents  her  being  able  to  empty  it,  I  would 
as  soon  find  this  out  after  operation  as  before.  We  can  see 
and  feel,  and  accurately  locate,  an  enlarged  bladder  if  it  is  dis- 
tended ;  lying  flat  and  empty  over  a  growth,  we  may  unwittingly 
injure  it.  If  the  bladder  contains  so  much  urine  as  to  be  in  the 
way  of  the  operator,  it  may  be  emptied  by  an  assistant :  this, 
however,  will  rarely  be  necessary. 

If  the  patient  is  of  the  lower  classes,  it  will  be  well  that  she 


PREPARATION   OF   PATIENT.  57 

should  have  a  warm  bath,  and  have  her  skin  well  cleansed  with 
soap  and  water.  Apart  from  the  increase  of  comfort, — a  result 
not  to  be  lightly  estimated, — the  advantages,  in  aiding  free 
cutaneous  action  by  removing  layers  of  effete  epidermic  scales 
and  accumulated  dirt,  must  be  considerable,  especially  in  cases 
where  the  renal  functions  are  not  quite  normal.  At  the  site  of 
the  wound,  particular  care  is  to  be  taken  with  the  cleansing 
process.  The  parts  are  soaked  for  twenty-four  hours  previously, 
by  several  layers  of  lint  containing  1-20  carbolic  lotion;  and 
the  umbilicus  and  pubes  are  scrubbed  with  a  nail-brush.  The 
pubic  hair  need  not  be  shaved  :  septic  matters  lodge  rather  in 
the  hair  follicles  than  upon  the  hair  itself. 

Operating  Table. — Any  ordinary  operating  table  will  suffice. 
It  should  be  narrow,  and  it  should  not  be  low.  A  simple  deal 
board,  about  two  feet  broad,  placed  between  trestles  or  tables, 
or  any  other  solid  support,  makes  an  excellent  operating  table. 
The  height  of  it  should  be  regulated  according  to  the  height  of 
the  surgeon.  Nothing  is  more  tiring  than  to  bend  over  the 
work  during  a  long  operation  ;  and  such  weariness  would 
undoubtedly  tell  upon  manual  dexterit3^  A  table,  three  feet  to 
three  feet  four  inches  in  height,  will  elevate  the  patient  so  that 
the  surgeon  can  stand  up  to  his  work.  The  patient's  arms  are 
confined  by  a  piece  of  bandage  or  broad  webbing  carried  round 
the  operating  table,  and  fixed,  by  a  clove-hitch  or  other  con- 
venient means,  around  the  wrist.  The  legs  are  confined  by 
tj'ing  the  bandage  over  the  knees  and  under  the  table.  For 
confining  the  arms  I  am  in  the  habit  of  using  the  well-known 
wristlets  invented  by  Mr.  Prichard  for  lithotomy ;  the  hooks 
being  fixed  into  holes  made  in  a  broad  piece  of  webbing  which 
is  passed  under  the  operating  table.  Apparatus  specially  made 
for  the  purpose  may  be  purchased. 

Coverings. — In  every  case  the  patient  should  be  so  wrapped 
up  that  as  little  as  possible  of  the  body  heat  will  be  lost.  Two 
warmed  blankets  are  placed  on  the  operating  table,  and  folded 
separately,  so  that  one  can  be  turned  over  the  front  of  the  lower 
limbs,  and  the  other  over  the  chest  and  upper  abdomen.  If  it 
seems  advisable  to  take  extra  care  to  keep  the  patient  warm,  a 


58  OPERATIVE  SURGERY  OF  ABDOMEN. 

layer  of  cotton  wool  over  the  chest  and  under  the  flannel  jacket, 
and  rolls  of  wool  around  the  limbs  under  the  blankets,  may  be 
added. 

When  the  patient  is  properly  protected  against  cold,  the 
whole  body,  from  chin  to  feet,  is  covered  with  a  sheet  of  mac- 
intosh in  which  an  opening  has  been  made,  of  size  and  shape 
convenient  for  exposing  the  area  in  which  the  operation  is  to  be 
done.  An  oval  opening,  about  seven  inches  long  by  four  broad, 
will  be  found  suitable  for  the  majority  of  operations ;  the  sheet 
itself,  so  as  completely  to  cover  the  patient  and  to  hang  over 
the  sides  of  the  table,  must  be  about  six  feet  square.  The 
opening  is  made  about  two  feet  from  the  top. 

On  the  under  surface  of  this  macintosh  sheet,  around  the 
margin  of  the  opening,  is  spread  adhesive  material,  such  as  is 
used  on  ordinary  adhesive  plasters ;  the  edges  of  the  opening 
are  thereby  made  to  adhere  closely  to  the  skin,  leaving  exposed 
only  as  much  of  the  abdominal  wall  as  is  necessary  for  operating. 
The  impervious  sheet  prevents  loss  of  heat  by  evaporation,  and 
keeps  the  patient  and  her  coverings  clean. 

In  every  abdominal  operation  I  should  use  this  sheet  of 
macintosh.  Its  virtues  may  be  more  conspicuous  in  the  removal 
of  large  cystic  growths,  where  it  keeps  the  patient  dry  and 
serves  to  guide  the  fluid  into  the  receptacle  provided,  than  in 
small  or  solid  growths,  where  such  uses  may  not  be  called  for. 
But  bowels  may  be  extruded  in  any  abdominal  operation ;  and 
blankets,  towels,  or  sheets  may  become  displaced  and  get  in  the 
way.  The  impervious  rubber  sheeting,  when  washed,  provides 
a  field  for  operation  which  is  always  clean,  and  it  keeps  every- 
thing else  out  of  the  way. 

A  sponge-cloth,  wrung  out  of  warm  antiseptic  lotion,  laid 
over  the  macintosh  below  the  field  of  operation,  will  be  found 
very  useful  for  wiping  soiled  fingers  upon,  and,  if  requisite,  for 
throwing  over  extruded  intestines. 

Warmth. — It  is  not  wise  to  operate  in  a  room  under  60°  Fah.; 
but  the  necessity  of  warming  the  room  up  to  70°  Fah.  need  not  be 
insisted  upon.  Evaporation  is  the  chief  cause  of  cooling  of  the 
peritoneum  ;  and  this  is  prevented  by  packing  into  the  exposed 


ASSISTANCE.  59 

cavity  soft  warmed  sponges,  and  by  protecting  extruded  viscera 
with  large  flat  sponges,  or  several  layers  of  thick  soft  cloth. 
General  warmth  of  the  body  is  maintained  by  the  method 
indicated. 

Light. — The  use  of  artificial  light  during  daylight  for  the 
purpose  of  searching  for  bleeding  points  in  the  deep  parts  has 
been  recommended.  For  this  purpose  an  electric  lamp  is,  for 
obvious  reasons,  undoubtedly  the  best.  I  have  no  experience 
of  the  electric  lamp,  and  have  never  found  the  necessity  for  its 
use  ;  though,  in  a  badly-lighted  room  on  a  dark  day,  I  can 
readily  conceive  that  it  might  prove  of  great  assistance.  A 
hand  mirror  is  often  useful  for  throwing  reflected  light  into  the 
cavity. 

Assistance. — Besides  the  anaesthetist,  one  assistant  is  all  that 
is  wanted  for  most  abdominal  operations.  Such  an  assistant 
ought  to  be  familiar  with  the  methods  of  the  operating  surgeon ; 
able,  with  swiftness,  precision,  and  dexterity,  to  second  and 
facilitate  his  proceedings  at  every  step.  He  must  have  no 
opinions  of  his  own  as  to  operative  details,  but  try  to  follow 
implicitly  the  mental  direction  of  his  chief.  His  duties  are 
simply  those  of  the  operator ;  he  acts  as  his  third  or  fourth 
hand.  A  skilled  assistant  is  thus  on  the  high  road  to  becoming 
a  skilled  operator ;  and  he  frequently  reaches  this  goal.  If  an 
unskilled  assistant  has  to  be  used,  I  think  a  medical  student  is 
of  more  use  than  a  tried  surgeon  who  has  no  experience  in 
abdominal  surgery.  The  student  will  do  what  he  is  told,  and 
no  more.  As  a  matter  of  fact,  in  most  cases  of  abdominal 
surgery,  an  assistant  of  any  sort  is  a  luxury  rather  than  a 
necessity.  As  personal  experience  increases,  the  two  hands 
become  capable  of  doing  more  and  more ;  and,  with  the  excep- 
tion of  some  minor  manipulations,  which  might  easily  be 
performed  by  a  nurse,  the  surgeon  can  do  most  things  without 
assistance  of  any  sort.  But  the  unexpected  often  happens  in 
abdominal  surgery,  and  the  presence  of  a  skilled  assistant  in 
any  of  the  numerous  accidental  emergencies  will  so  frequently 
be  of  conspicuous  advantage,  that  it  will  be  wise  never  to 
operate  without  his  presence. 


60  OPERATIVE   SURGERY   OF  ABDOMEN. 


ANTISEPTICS. 

The  most  perfect  surgery  is  aseptic,  rather  than  antiseptic. 
All  antiseptics  are  more  or  less  irritating,  and  thereby  to  some 
extent,  however  small,  harmful  to  the  peritoneum  ;  if  there 
is  no  septic  material  in  the  air,  fluids,  fingers,  sponges,  or 
instruments  that  come  into  contact  with  the  wound  or  peri- 
toneum, antiseptics  are  also  useless.  That  perfect  purity  of 
every  material  which  touches  the  inside  of  the  abdomen  is 
absolutely  essential,  all  are  agreed ;  the  only  questions  in  dis- 
pute are,  as  to  whether  the  air  also  ought  to  be  purified — that 
is,  whether  the  steam  spray  should  or  should  not  be  used  ;  and 
whether  antiseptic  lotions  should  be  used  for  cleansing. 

When  the  spray  is  condemned  as  harmful  by  such  men  as 
Keith  and  Tait  on  the  one  hand,  and  upheld  as  beneficial  by 
such  men  as  Thornton  and  Wells  on  the  other,  we  may  safely 
conclude  that,  under  an}-  circumstances  which  may  be  common 
to  all  their  patients,  it  is  unimportant.  Spray,  or  no  spray,  is 
probably  a  choice  of  evils,  and  of  not  very  great  evils.  On  the 
one  side,  the  evil  is  irritation  of  the  peritoneum,  from  the 
germicide  ;  cooling  of  the  peritoneal  surfaces,  from  wetting  and 
evaporation  ;  and  poisoning,  from  absorption  of  the  antiseptic 
agent  used.  On  the  other  side,  the  evil  is  a  danger  to  be 
avoided — namely,  septic  peritonitis,  from  contamination  by  the 
surrounding  air. 

Now,  there  is  no  doubt  v/batever  that  the  greatest  risk  of 
peritonitis  arises  from  impurity  of  hands,  sponges,  and  instru- 
ments, and  not  from  air.  The  spray  has  little  influence  over 
these  :  but  repeated  cleansing  with  soap  and  water  will  render 
them  practically  pure.  An  antiseptician  who  scrupulously 
attends  to  cleansing  of  hands  and  instruments  is  in  a  better 
position  than  one  who  places  all  his  trust  in  the  spray.  And, 
as  a  matter  of  fact,  those  who  object  to  the  spray  do,  all  of 
them,  most  thoroughly  and  efficiently  purify  fingers,  sponges, 
and  instruments.  It  has  become  evident  that  many  surgeons, 
with  implicit  belief  in  Listerism,  trust  too  much  to  carbolic  acid 
or  its  allies,   and  pay  too  little  attention  to  the  cleansing  of 


ANTISEPTICS.  61 

sponges  and  fingers,  by  simply  removing  the  filth,  rather  than 
disinfecting  it.  Herein  non-antisepticians — or,  as  they  might 
more  justly  be  called,  asepticians — teach  a  lesson  which  it 
would  be  well  for  all   to  follow. 

The  dangers  of  the  spray  in  ordinary  operations  are  un- 
doubtedly very  small.  It  is  easy  enough  to  protect  the  peri- 
toneum by  sponges,  and  to  prevent  cooling  of  the  abdominal 
surface  by  a  macintosh  cloth.  Carboluria  in  these  cases  is  very 
rare ;  and  even  if  it  comes  on,  it  is  practically  always  slight  and 
evanescent.  In  the  case  of  prolonged  and  difficult  operations, 
where  the  peritoneum  must  be  exposed  for  the  separation  of 
adhesions,  the  dangers  of  the  spray  are  undoubtedly  real,  if 
they  are  not  great.  Here,  personal  experience  is  everything. 
Thornton  has  strongly  expressed  his  belief  in  its  freedom  from 
danger ;  and  other  operators,  American  and  continental,  agree 
with  him.  Personally,  speaking  from  an  experience  of  cases 
which,  from  various  causes,  have  been  of  more  than  average 
difficulty,  I  have  seen  the  spray  do  no  harm. 

The  practical  outcome  of  the  teaching  of  modern  surgery  is 
probably  this.  All  bodies  that  come  into  contact  with  the 
wound  or  peritoneum  are  to  be  made  thoroughl}^  clean  and 
aseptic.  The  operation  must  be  performed  in  air  that  is  not 
only  free  from  contamination,  but  very  approximately  pure. 
If  the  air  is  not  in  this  wholesome  condition,  then  it  must  be 
purified  by  the  use  of  an  antiseptic  spray,  either  in  the  room 
before  operation,  or  over  the  abdomen  during  the  operation. 
In  all  cases  of  doubt  as  to  the  condition  of  the  air — and  such 
cases  must  be  common — it  is  wise  to  use  the  spray.  And  some 
weight  must  be  given  to  the  personal  experience  and  habits  of 
the  surgeon.  A  man  who  is  thoroughly  conversant  with  the  use 
of  the  spray,  who  knows  exactly  how  strong  it  may  be  made, 
and  how  best  its  evil  effects  may  be  minimised,  will  be  loth  to 
dispense  with  the  security  it  affords,  even  where  surroundings 
appear  to  be  most  favourable.  Another,  who  uses  it  as  a  sort 
of  experiment  (and  there  are  still  many  such),  or  who  has 
already  come  to  have  confidence  in  his  own  methods  without 
spray,  will  probably  decide  against  it.     If  it  is  possible  to  create 


62  OPERATIVE   SURGERY  OF  ABDOMEN. 

a  bias  one  way  or  the  other,  I  think  it  ought  to  be  towards  the 
spray.  If  the  points  in  dispute  are  narrowed  down  to  carboHc 
poisoning  on  the  one  hand,  and  septic  poisoning  on  the  other, 
I  should  not  hesitate  as  to  which  I  should  seek  to  ward  off  from 
my  patient. 

The  Steam  Spray. — If  the  antiseptic  spray  is  used,  certain 
practical  details  must  be  attended  to.  We  must  employ  the 
least  amount  of  spray  compatible  with  efficienc}^  One  nozzle 
is  sufficient,  if  it  throws  a  large  finely  divided  cloud.  A  cloud 
that  is  dense  and  coarse  is  particularly  to  be  avoided.  It  will 
be  found  that  different  apparatus  throw  out  very  different  qualities 
of  spray.  Some  instruments  at  ordinary  pressure,  with  carbolic 
lotion  of  the  strength  of  1-20  in  the  bottle,  will  cast  a  spray  of 
1-50;  while  others,  under  the  same  conditions,  will  cast  a 
spra)'  of  1-30  strength.  Every  spray-producer  should  be  tested 
by  putting  measured  quantities  of  water  and  of  lotion  into  the 
boiler  and  the  bottle,  and  estimating  the  amount  used  up  after 
a  given  time.  The  position  of  the  spray  also  is  important. 
I  believe  that  carboluria  may  be  caused  by  inhalation  of  spray 
(the  writer  always  has  this  symptom  after  a  prolonged  operation 
in  a  carbolised  atmosphere) ;  and  to  avoid  this,  the  apparatus 
must  be  placed  so  that  the  cloud  does  not  envelope  the  patient's 
head.  This  will  be  secured  by  placing  the  instrument  opposite 
the  patient's  left  shoulder,  at  a  distance  of  about  six  feet  or 
more  from  the  wound. 

SURGICAL    ARMAMENTARIUM. 

Sponges:  their  Selection,  Preparation,  and  Purification. — The 
very  finest  Turkey  sponges  should  be  used.  It  is  difficult, 
even  in  large  collections,  to  find  the  sort  of  sponge  that  is 
suitable  for  abdominal  surgery.  They  must  be  very  soft,  of  the 
finest  texture,  elastic  and  compressible,  and  of  various  shapes 
and  sizes.  Several  very  large  thin  and  flat  sponges  are  neces- 
sary to  cover  extruded  bowels  or  omentum  on  which  a  number 
of  compression  forceps  may  have  been  placed.  A  number  of 
somewhat  flat  sponges,  of  about  the  area  of  the  open  hand,  are 
requisite  for  packing  inside  the  abdomen,  to  prevent  extrusion 


SPONGES.  63 

of  bowels,  and  to  absorb  blood  and  fluid  during  the  separation 
of  adhesions.  Lastly,  small  round  sponges  are  necessar}-  for 
general  purposes — for  sponging  the  wound,  for  packing  into 
spaces  where  large  ones  will  not  go,  and  for  mopping  out  the 
peritoneal  cavity. 

The  preparation  and  purification  of  sponges  requires  the 
most  careful  and  close  attention.  This  duty  cannot  safely  be 
relegated  to  assistants ;  the  surgeon  must  do  it  with  his  own 
hands.  The  sponges  are  first  cleansed  from  the  sand  which 
occupies  their  meshes  by  repeated  washings  in  water.  At  the 
end  of  about  a  week,  the  water  having  been  changed  at  least 
twice  daily,  all  the  large  fragments  will  have  been  washed  out. 
They  are  left  for  three  or  four  days  longer  in  water  acidulated 
with  hydrochloric  acid,  in  amount  sufficient  to  make  the  fluid 
taste  distinctly  of  the  chemical.  This  bleaches  the  sponges  a 
little,  but  scarcely  alters  their  texture.  They  are  then  (according 
to  one  method),  after  washing  in  pure  water  to  remove  the  acid, 
placed  in  a  solution  of  ordinary  washing  soda  (about  a  pound  of 
soda  to  the  dozen  sponges  is  the  proportion  that  Tait  advises), 
and  left  there  for  not  more  than  twenty-four  hours.  They  are 
washed  and  squeezed  several  times  in  this  fluid,  which  they 
render  slightly  cloudy.  They  are  now  very  soft.  Finally,  after 
being  taken  through  clean  water  to  remove  the  soda,  the}'  are 
soaked  for  a  few  hours  in  1-20  carbolic  lotion,  squeezed  as  dry 
as  possible,  and  artificially  dried  by  heat.  When  they  are 
perfectly  dry,  they  are  laid  aside  in  a  dry  place,  well  covered  up, 
till  they  are  wanted. 

After  an  operation  the  sponges  may  be  purified  in  a  some- 
what similar  manner.  Having  been  washed  in  water  to  remove 
as  much  of  the  filth  as  possible,  they  are  placed  in  the  soda 
solution,  which  effectually  dissolves  out  the  blood  and  fibrine, 
and  repeatedly  washed  and  squeezed  in  it.  The  soda  solution 
is  changed  several  times.  When  ever}-  particle  of  filth  has  been 
removed,  they  are  cleansed  in  water,  dipped  in  carbolic  solution, 
squeezed  and  dried,  and  kept  in  a  dry  place  till  further  use. 

Another  very  excellent  mode  of  cleansing  sponges  is  recom- 
mended by  Borham,     After  giving  it  a  full  trial,  I  have  adopted 


64  OPERATIVE   SURGERY   OF  ABDOMEN. 

it  entirely  in  preference  to  other  methods.  The  sponges  are  first 
soaked  in  a  one-per-cent.  sohition  of  permanganate  of  potash ; 
the  permanganate  is  then  washed  out  by  repeated  squeezings  in 
fresh  water.  This  part  of  the  proceeding  may  be  neglected ;  I 
doubt  if  it  is  of  much  value.  The  sponges,  ten  or  twelve  in 
number,  are  then  placed  in  a  gallon  of  water,  in  which  half  a 
pound  of  sodium  hyposulphite  has  been  dissolved  ;  the  amount 
of  solution  being  increased  according  to  the  number  of  sponges. 
Then  about  four  ounces  of  oxalic  acid  are  added,  and  a  chemical 
action  takes  place  which  rapidly  bleaches  the  sponges  and  dis- 
solves out  any  fibrine  contained  in  their  meshes.* 

The  sulphur  dioxide  is  a  powerful  disinfectant  as  well  as  a 
bleaching  agent,  and  being  generated  in  the  meshes  of  the 
sponges,  reaches  every  part  of  them.  The  sodium  oxalate  acts 
as  a  softening  agent  and  dissolves  out  the  fibrine.  It  takes  a 
good  many  washings  in  water  to  get  rid  of  the  free  sulphur ;  but 

*  Mr.  W.  A.  Shenstone,  Chemical  Master  at  Clifton  College,  has  very 
kindly  supplied  me  with  the  following  explanation  of  the  reaction  : — 

The  use  of  sodium  hyposulphite  (properly  sodium  theiosulphate)  no  doubt 
depends  upon  the  formation  of  a  solution  of  sulphur  dioxide,  SO.,,  according  to 
the  equation — 

Na^  S,0,  +  H2  C„0^  =  Na^CjO,  +  SO,,   +  S  4-  H„0. 

The  rather  tardy  appearance  of  the  precipitate  of  sulphur  being  possibly 
due  to  formation,  in  the  first  instance,  of  hyposulphurous  acid,  H^  S„  O3, 
which,  however,  if  formed  speedily  undergoes  decomposition  according  to  the 

equation — 

H2S2O3  =  H.,0  +  SO,  +  S. 
If  the  precipitate  of  sulphur  that  accompanies  the  sulphur  dioxide  be  objected 
to,  sodium  sulphite  (Na^SOj  TH^O),  may  conveniently  be  substituted  for  the 
sodium  hyposulphite. 

Small  quantities  of  sulphuric  acid  are  formed  in  the  bleaching  process, 
and  a  solution  of  sulphur  dioxide  absorbs  oxygen  from  the  air  with  pro- 
duction of  sulphuric  acid ;  therefore,  as  the  presence  of  this  compound  in 
the  water  that  remains  adherent  to  the  sponges  when  they  are  placed 
aside  to  dry  tends  to  rot  them,  they  must  be  very  thoroughly  washed  with 
pure  water  after  treatment  with  the  bleaching  liquid.  From  the  above 
equation  it  will  be  seen  that  the  hyposulphite  and  the  acid  may  conveniently 
be  used  in  molecular  proportions.  Both  oxalic  acid  and  sodium  hyposulphite 
crystallise  with  water  of  crystallisation  however  (NajS^Og  5H.^O  and 
HoCjO^  2H2O),  and,  therefore,  they  should  be  used  in  the  following  pro- 
portions, viz. :  248  parts  of  crystallised  sodium  hyposulphite  to  126  parts  of 
oxalic  acid.  In  practice  two  parts  of  the  salt  to  one  of  the  acid  will  be  a 
sufficiently  close  approximation  to  these  theoretical  numbers. 


LIGATURES  AND   SUTURES.  65 

this  is  rather  an  advantage  than  otherwise,  for  if  we  follow  the 
rule  never  to  consider  the  sponges  cleansed  till  the  water 
squeezed  out  of  them  is  quite  clear,  this  freedom  from  sulphur 
is  a  good  working  test  of  the  purity  of  the  sponges.  Sulphur 
itself  is  a  mild  antiseptic  (from  slow  oxidation  and  formation 
of  sulphur  dioxide) ;  and  the  sponges  may  at  once  be  dried 
and  laid  aside  after  washing.  I  usually  dip  them  in  carbolic 
acid,  however,  before  doing  so.  If  the  precipitate  of  sulphur  is 
objected  to,  sodium  sulphite  may,  as  Mr.  Shenstone  suggests,  be 
used  instead  of  sodium  hyposulphite. 

The  sponges,  for  reasons  explained  in  the  foot-note,  must  not 
remain  in  the  solution  longer  than  ten  minutes. 

Ligatures  and  Sutures.— For  ligatures  the  best  material  is  silk 
of  the  variety  known  as  Chinese  twist ;  for  sutures,  either  silk- 
worm gut  or  plaited  silk  such  as  are  used  in  rod-fishing. 

As  material  for  ligature  there  is  no  strong  objection  to  cat- 
gut ;  I  have  used  it  and  nothing  else  in  more  than  twenty 
ovariotomies,  and  found  it  perfectly  reliable.  Its  drawbacks 
are,  the  trouble  necessary  for  its  perfect  preparation,  and  its 
tendenc}^  to  deteriorate  by  keeping ;  such  drawbacks  being,  in 
my  opinion,  of  sufficient  weight  to  justify  its  being  displaced  by 
the  more  handy  and  equally  trustworthy  silk  twist. 

Chinese  twist  is  made  in  different  sizes;  the  sizes  ^,  2,  4,  and 
6  are  quite  sufficient  for  all  practical  purposes  in  abdominal 
surgery.  The  thickest  is  strong  enough  to  bear  as  much  strain 
as  a  very  powerful  man  can  put  upon  it,  and  is  used  for  tying 
thick  pedicles  ;  the  thinnest  is  adapted  for  the  finest  work,  such 
as  suture  of  wounds  in  bladder  or  intestine.  The  medium  sizes 
are  used  for  tying  thin  pedicles  and  ordinary  adhesions.  For 
holding  these  four  varieties  of  silk,  I  have  had  a  stand  made 
which  is  very  portable  and  always  ready  for  use.  It  consists  of 
a  solid  rubber  case,  on  to  which  is  screwed  a  cap  which  keeps  it 
practically  air-tight.  (Fig.  4.)  Into  this  case  fits  a  leaden  disc, 
which  is  heavy  enough  to  remain  stationery  while  the  silk  is 
being  drawn  out ;  and  on  this  disc,  supported  by  upright  rods  of 
metal,  are  placed  the  four  reels.  A  glass  plate,  perforated  in 
four  places  for  the  threads,  is  screwed  on  to  the  top  of  a  central 

6 


66 


OPERATIVE  SURGERY  OF  ABDOMEN. 


bar.  Before  using  it,  the  leaden  disc  with  the  reels  and  thread 
is  placed  in  boiling  water  for  ten  minutes,  and  then  returned  to 
its  case,  into  which  sufficient  i — 20  carbolic  lotion  has  been 
placed  to  cover  the  glass  plate.  To  prevent  their  being  acted 
upon  by  boiling  water  the  reels  are  made  of  metal,  and  to 
prevent  rusting  all  the  metal  is  nickel-plated.  After  being 
used  the  lotion  is  poured  out  a'nd  the  cap  screwed  on. 
The  silk,  treated  and  protected  in  this  wa}^  may  be  used 
daily,  without  further  boiling,  for  several  weeks :  none  is 
wasted ;  it  is  just  as  trustworthy  at  the  end  of  six  weeks 
as  at  the  end  of  six  days ;  it  is  always  ready  for  use,  and 
the  apparatus  is  so  simple  that  it  can  scarcely  get  out  of  order. 
For  suturing  the  parietal  wound,  I  have  come  to  the  con- 
clusion, after  giving  it  an  ex- 
tensive trial,  that  no  material 
is  superior  to  silk-worm  gut  as 
introduced  by  Bantock.  In 
every  variety  of  surgical  oper- 
ation I  have  tried  it,  and 
ever3'where  it  exhibits  the 
same  virtue  in  causing  no 
irritation.  I  have  purposely 
left  it  in  the  tissues  for  weeks, 
and  even  months,  and  I  have 
never  seen  its  presence  fol- 
lowed b}-  the  formation  of' 
pus.  In  the  sense  of  being 
unirritating  it  is  superior  to 
any  suture  material  with 
which  I  am  acquainted.  Its 
drawbacks  are,  that  it  is 
somewhat  stiff,  not  very  easy 
to  manipulate  till   one  is 

familiar  with  it,  and  rather  friable,  being  liable  to  break  if  the 
second  cast  in  the  knot  is  pulled  too  tightly.  The  stiffness  may 
be  partl}^  removed  by  soaking  in  warm  wather  for  ten  minutes 
before   operation,    and    the    danger   of    its   breaking    may   be 


Fig.  4. 
The  Author's  Reel-holder. 


Half  size 


INSTRUMENTS.  67 

lessened  by  making  the  first  cast  a  double  one  and  tying  the 
second  one  very  lightly.  Another  objection,  which  at  the  same 
time  speaks  in  its  favour,  is  that,  when  the  suture  is  being 
removed,  it  lies  so  firmly  embedded  in  the  tissues  that  a  some- 
what sharp  tug  is  required  to  drag  it  out  of  its  bed.  This, 
however,  may  be  because  the  suture  needle  w^hich  I  use  is 
smaller  than  ordinary.  The  strongest  objection,  in  my  opinion, 
to  silk-worm  gut  arises  in  cases  where  there  is  much  straining 
and  vomiting ;  then  it  may  cut  through  the  tissues.  In  one  such 
case  where  the  incision  extended  through  the  umbilicus,  the  gut 
cut  clean  through  the  thin  tissues  and  permitted  protrusion 
of  bowels.  Care  in  selecting  only  such  threads  as  are  round 
and  thick  may  obviate  this  ;  but  I  should  always  advise  the 
placing  of  a  few  thick  silk  sutures  at  points  where  the  parietes 
are  thin,  in  cases  where  abdominal  strain  is  likely  to  be 
produced. 

The  gut  is  that  ordinarily  used  by  fishermen,  and  need  not 
be  described.  I  have  found  the  best  gut  in  the  shops  of  good 
fishing-tackle  makers  ;  in  the  ordinar}'  trade  bundles,  perhaps  a 
dozen  threads,  specially  smooth,  round,  and  thick,  are  found 
suitable  for  surgical  purposes. 

After  silk- worm  gut,  as  suture  material,  I  should  place  the 
plaited  silk  recently  patented  for  use  as  fishing  lines. 

Its  chief  advantage  over  twisted  silk  is  that  it  does  not  kink 
in  the  eye  of  the  needle  or  in  the  suture  openings,  while  it 
is  more  closely  knit  and  does  not  offer  so  large  a  surface  for 
absorption  of  inflammator}^  products.  It  is  also  very  strong. 
The  trade  reels  of  plaited  silk  used  in  the  suture  instrument  to 
be  presently  described  makes  a  handy  and  efficient  suture 
apparatus. 

Instruments. — The  instruments  to  be  used  in  an  abdominal 
operation  must  be  thoroughly  clean ;  they  must  be  conveniently 
placed  within  reach  of  the  operator's  hand  ;  and  they  must  be  of 
a  known  number. 

Cleanliness,  in  the  fullest  sense  of  the  word,  is  an  absolutely 
essential  quality  of  every  instrument.  To  ensure  this,  all  steel 
instruments  (not  cutting)  should  in  the  first  place  be  nickel- 

6  * 


68  OPERATIVE  SURGERY   OF   ABDOMEN. 

plated.  Then  filth  is  less  likely  to  be  overlooked,  and  not  liable 
to  be  mistaken  for  rust  or  tarnish.  After  every  operation  they 
should  be  thoroughly  cleansed  and  dried  ;  and  before  every 
operation  they  must  again  be  purified.  Some  surgeons,  before 
operation,  hold  every  instrument  for  a  little  while  in  the  flame  of 
a  spirit  lamp  ;  others  subject  them  to  boiling.  Practically  it  will 
be  found  that  scrubbing  with  a  brush,  and  the  use  of  an  anti- 
septic lotion,  will  efficiently  purify  every  instrument.  Smooth 
surfaces  may  be  wiped  several  times  with  a  sponge-cloth  soaked 
in  lotion  ;  irregular  surfaces  and  joints  must  be  scrubbed.  The 
notched  blades  and  the  joints  of  catch-forceps  require  most 
attention.  A  good  plan  is  to  dip  the  blades  of  each  forceps  into 
a  dish  containing  soft  soap,  and  then  scrub  it  with  the  brush 
dipped  in  hot  water  till  lather  ceases  to  form.  Nothing  softens 
filth  better  than  soft  (potash)  soap ;  and  when  every  particle  of 
soap  has  been  scrubbed  out  of  the  notches  and  recesses  of 
instruments,  we  may  be  certain  that  no  filth  is  left  behind. 
After  they  are  scrubbed  the  instruments  are  thrown  into  hot 
water  and  left  there  for  a  few  moments.  Then  they  are  placed 
in  fluid,  water  or  lotion,  as  the  case  may  be,  to  be  ready  for  use. 
Carbolic  lotion  of  the  strength  of  1-40  is  the  best  antiseptic 
fluid  for  placing  instruments  in ;  corrosive  sublimate  is  in- 
admissible, because  of  its  action  upon  steel. 

Flat  trays,  an  inch  or  more  in  depth  and  of  various  sizes,  are 
used  for  placing  the  instruments  in.  Porcelain  trays  such  as  are 
used  by  photographers  are  best,' because  they  are  easily  cleansed, 
are  impervious  to  acids,  and,  being  white,  show  up  instruments 
laid  in  them.  As  they  are,  however,  somewhat  cumbersome 
and  fragile,  they  are  not  very  convenient  for  being  carried  about 
to  private  operations.  For  use  in  private  hard  rubber  trays  are 
best.  They  may  be  procured  in  "nests"  of  all  sizes;  and  four 
or  five  such,  of  dimensions  suitable  to  the  nature  of  the  in- 
struments to  be  used,  may  be  put  in  the  operation  bag,  the 
total  space  occupied  being  no  more  than  the  largest  tray.  Each 
tray  has  its  variety  of  instrument.  In  one  are  the  cutting 
instruments  ;  in  another,  the  small  catch-forceps ;  in  another, 
large  forceps ;  in  another,  trocars  or  clamps,  or  drainage  tubes ; 


THE   OPERATING   ROOM.  69 

and  so  on  according  to  the  instruments  to  be  employed.  Every 
instrument  is  removed  from  its  tray  by  the  surgeon  himself  as  he 
wants  it,  and  after  being  used  is  at  once  replaced  in  the  fluid. 

The  instruments  should  be  counted  before  each  operation,  so 
that  there  may  be  no  possibility  of  leaving  instruments  inside. 
In  the  case  of  bulky  instruments  this  mistake  is  not  likely  to 
happen.  It  is  a  good  plan  to  always  work  with  simple  multiples 
of  each  instrument;  for  example,  in  the  case  of  pressure  forceps, 
which  are  most  likely  to  be  lost :  twelve  pairs  of  smallest  size  in 
one  tray  ;  six  pairs  of  medium-size  in  another  tray ;  and  six 
pairs  of  large  size  in  a  third  tray.  The  habit  of  having  two  or 
three  instruments  of  one  sort  laid  out,  in  case  one  is  found 
faulty,  is  not  a  good  one  ;  each  instrument  should  be  tested  and 
ascertained  to  be  perfect  before  operation.  The  surgeon  who 
has  two  or  three  scalpels  and  two  or  three  pairs  of  scissors  laid 
out  for  operation  is  not  likely  to  be  so  well  served  as  he  who  has 
only  one  of  each. 

Plan  of  Operating  Room. — The  placing  of  patient,  assistants, 
nurses,  instruments,  and  operators  so  that  the  operation  may  be 
carried  out  with  the  greatest  efficiency  and  the  least  amount  of 
friction  is  of  some  importance.  The  annexed  diagram  (Fig.  5), 
modified  from  the  one  in  Doran's  valuable  work,*  shows  at  a 
glance  the  arrangement  which  I  consider  best.  For  reasons  I 
have  already  explained  the  steam  spray  is  so  placed  that  the 
patient  is  not  forced  to  inhale  its  vapour.  The  direction  of  the 
cloud  is  obliquely  across  the  field  of  operation,  and  envelopes 
the  hands  of  the  assistant  and  of  the  operator  as  well  as  the 
instruments  and  the  field  of  the  operation.  In  the  arrangement 
shown  in  Doran's  work,  I  think  it  is  a  disadvantage  that  the 
instruments  are  placed  outside  the  spray-cloud  ;  and  a  danger  to 
have  the  spray  directed  towards  the  patient's  mouth.  The 
operator  stands  on  the  right  of  the  patient  and  the  assistant  on 
the  left.  The  instruments  are  arranged  in  trays  placed  side  by 
side  on  a  table,  which  is  situated  within  easy  reach  of  the 
operator's  right  hand.  The  feet  of  the  patient  are  towards  the 
window;  and  the  table  is  so  placed  that  the  best  lights  fall  upon 
*  Cynacological  Operations,  p.  200.        London,   1887. 


70 


OPERATIVE   SURGERY  OF  ABDOMEN. 


the  field  of  operation.  The  nurse  stands  behind  the  assistant, 
and  takes  from  him  soiled  sponges  and  supplies  him  with  clean 
ones.  The  fewer  hands  that  sponges  pass  through  the  better : 
one  nurse  can  easily  clean  the  sponges  and  supply  the  assistant 
with  clean  ones.  If  a  basin  containing  lotion  is  placed  under 
the  left  hand  of  the  assistant,  and  the  nurse  places  the  sponges, 
which  she  has  cleaned  in  a  large  pan  full  of  hot  water,  in  this 


Wfeix- 


pLOROroRKISTj 


"'li^ili^; 

'^\\<$$$ 

\\>>\ 

[receptacle  FOR  FmiDlx^'N^'v^  '^ 


TABLE.WITH..^ 

'instruments 

SI  trcATUHES 


Fig.  5. 

Diagram  sJwu'iug  position  of  Patient,  Surgeon,  Assistants,  &-c.,  in 
Abdominal  Operations. 

basin  as  they  are  cleaned,  the  assistant  can  help  himself  at  once 
to  any  sponge  he  wants,  and  as  he  helps  himself  he  squeezes  the 
sponge  dry — a  duty  which  the  nurse  often  fulfils  very  imper- 
fectly. It  is  not  pleasant  to  hear  the  assistant  call  out  for  a 
"large  flat  sponge"  or  a  "small  round  sponge"  as  the  surgeon 
wants  it ;  it  should  be  lying  ready  to  his  hand,  and  he  should  be 
able  silently  to  help  himself  the  moment  the  surgeon  wants  it, 
or  he  foresees  its  usefulness. 

For  ovariotomy  a  receptacle  is  placed  partly  under,  partly 


THE   OPERATION.  71 

by  the  side  of,  the  table  for  holding  ovarian  fluid.  A  long 
narrow  trough,  which  is  out  of  the  way  of  the  surgeon's  legs  and 
includes  half  the  length  of  the  table,  is  most  convenient. 

If  a  second  assistant  is  wanted,  he  ma}'  stand  on  the  left  side 
of  and  behind  the  operator, 

ANESTHETIC. 

Ether,  properl}'  administered  by  means  of  a  Clover's  in- 
haler, is  generally  believed  to  be  the  best  anaesthetic.  For 
old  patients,  or  for  patients  who  are  bronchitic,  chloroform 
is  perhaps  safer.  Chloroform  and  ether  mixed  is  favoured  by 
some  surgeons  of  repute.  Bichloride  of  meth3dene,  which  is 
used  at  the  Samaritan  Free  Hospital,  has  not  been  generally 
adopted.  In  all  cases,  I  believe  that  safety  and  efficiency 
depend  more  on  the  capacity  of  the  administrator  than  on  the 
nature  of  the  anaesthetic. 

THE    OPERATION    ITSELF. 

The  Incision  through  the  Parietes. — A  sharp  scalpel,  a  few  catch 
forceps,  and  a  pair  of  scissors,  are  all  the  instruments  required 
for  this  purpose.  The  surgeon  may  suit  his  own  fanc}'  as  to  the 
scalpel  he  uses  ;  the  only  essential  is  that  it  be  sharp.  The 
most  delicate  workmanship  is  secured  if  the  cutting  edge  of  the 
knife  is  situated  at  a  distance  from  the  finger-tips,  which  is 
rendered  habitual  by  frequent  practice  in  other  directions.  This 
is  undoubtedly  the  position  of  the  point  of  a  pen  in  writing. 
The  point  of  the  scalpel  should  be  at  the  same  distance  from  the 
grasping  finger-tips  as  the  point  of  a  writing-pen  or  drawing- 
pencil,  as  these  are  held  by  the  individual  operator.  The 
advantages,  in  the  way  of  sensitiveness  and  estimation  of  move- 
ments, are  self-evident.  In  most  cases  this  would  mean  a  blade 
shorter  than  that  in  ordinary  use.  The  handle  of  the  scalpel 
should  not  be  too  small,  nor  too  light.  Clean,  straight  cuts 
from  end  to  end  of  the  wound,  and  not  nibbling  dissection,  with 
forceps  and  director,  are  to  be  made.  The  scalpel  penetrates 
exactly  the  same  distance  from  one  end  to  the  other,  and 
divides  the  same  structure  at  each  stroke. 


72  OPERATIVE  SURGERY  OF  ABDOMEN. 

It  is  an  advantage  to  have  the  scissors  elbowed  a  httle ;  and 
a  further  advantage  consists  in  having  the  lower  blade  probe- 
pointed,  to  facilitate  its  being  pushed  along  under  the  fasciae  or 
muscles  that  may  require  division.  The  proceeding  differs  some- 
what, according  to  the  situation  elected  for  incision.  In  the 
linea  alba  below  the  umbilicus,  where  the  great  majority  of 
incisions  to  enter  the  cavity  are  made,  no  muscle  is  divided. 
In  other  situations,  as  for  gastrostomy,  nephrectomy,  or  co- 
loton>3%  several  laj'ers  of  muscle  require  division.  P'or  dividing 
muscle,  I  believe  the  scissors  to  be  a  superior  instrument  to  the 
scalpel.  Few  English  surgeons  make  a  practice  of  using  scis- 
sors, and  some  little  practice  is  necessary  to  enable  one  to 
appreciate  its  virtues.  Scissors-cuts  are  clean  and  straight ; 
they  do  not  bleed  much,  because  compression  is  a  factor  in  the 
division ;  and  if  one  is  moderately  familiar  with  the  use  of 
scissors,  the  dissection  is  more  rapid  than  with  the  scalpel. 

The  scissors  usually  recommended  for  ovariotomy,  and  in 
use  at  the  Samaritan  Hospital,  is  a  large  instrument  with  flat 
blades,  bent  on  the  flat  near  the  hinge,  and  very  blunt-pointed. 
It  is  an  admirable  instrument  for  such  modes  of  cutting  as 
ovariotomy  offers,  being  well  adapted  for  dividing  adhesions, 
cutting  through  the  pedicle,  and  enlarging  the  parietal  wound. 
But  for  more  delicate  work,  such  as  division  of  layers  of  muscle, 
dissecting  closely  adherent  organs  from  their  attachments,  or  re- 
section of  intestine,  I  do  not  consider  it  so  handy  as  a  smaller 
instrument,  elbowed  a  little  and  with  smaller  and  more  rounded 
points.  But  much  depends  upon  habit  and  practice.  The  shape 
and  size  of  an  instrument  are  of  small  importance  as  compared 
with  the  surgeon's  familiarity  with  it. 

If  a  vessel  spouts,  a  catch-forceps  is  at  once  placed  on  it,  and 
left  there  till  the  peritoneum  has  been  opened,  or  as  long  as  de- 
sirable. A  few  minutes'  compression  b}'  forceps  produces  perfect 
haemostasis;  ligature  or  torsion  is  quite  unnecessary.  When  the 
subperitoneal  fat  is  reached,  a  little  area  is  cleared  out  of  it,  and 
the  peritoneum  caught  up  by  catch  forceps  and  pulled  forward. 
A  second  pair  of  forceps  is  placed  on  the  raised  fold  of  peri- 
toneum, and  the  membrane  divided  between  them.     The  fore 


INTRA-ABDOMINAL  OPERATIONS.  73 

finger  is  inserted  at  this  opening;  and  the  peritoneum  divided 
upon  it,  upward  and  downward,  by  scissors,  to  the  extent  of  the 
wound  on  the  parietes. 

In  the  division  of  layers  of  muscle,  it  is  just  as  foolish  to 
look  for  anatomical  divisions,  as  in  the  operation  of  herniotom}', 
to  look  for  the  individual  coverings  of  the  sac.  It  is  more 
workmanlike  to  estimate  by  touch  the  general  thickness  of  the 
abdominal  wall,  and  to  divide  the  muscles  with  a  few  large  cuts 
by  scissors,  than  to  plod  through  the  individual  layers  with 
director  and  scalpel.  When  the  subperitoneal  fat  is  reached,  it 
is  time  to  be  minutely  careful.  The  director  is  a  clums}^  and 
useless  instrument  in  abdominal  surgery ;  in  the  hands  of  the 
most  skilful  operators,  it  is  conspicuous  by  its  absence. 

The  length  of  the  incision  is  a  matter  of  some  importance. 
Elaborate  statistics  have  been  compiled  to  show  that  a  long 
incision  is  attended  with  an  increased  mortalit}' ;  but  this  is  not 
caused  by  the  incision  itself,  but  by  the  serious  nature  of  the 
work  inside  the  abdomen  which  necessitates  the  long  incision. 
The  smallest  incision  compatible  with  the  provision  of  sufficient 
room,  without  bruising  the  edges  of  the  wound,  is  to  be  adopted. 
All  lengths,  from  something  under  two  inches  in  cases  of  oopho- 
rectomy or  simple  ovarian  cysts,  to  the  whole  length  of  the 
abdomen  from  sternum  to  pubes,  as  for  some  cases  of  myo- 
motomy,  are  in  use. 

When  the  tumour  is  adherent  to  the  parietal  peritoneum, 
some  care  must  be  observed  in  effecting  an  entrance.  It  is  quite 
possible  to  mistake  the  adherent  peritoneum  for  the  cyst-wall, 
and  begin  to  strip  it  from  the  parietes.  We  may  expect  to  find 
peritoneum  adherent  to  tumour  if  there  is  more  than  ordinary 
bleeding  in  making  the  parietal  incision,  if  the  intermuscular 
fasciae  are  pink  in  colour,  or  if  the  subperitoneal  fat,  instead  of 
being  pale  yellow  or  white,  is  rosy-red  or  injected.  But  here 
also  experience  is  the  best  guide:  familiarity  with  the  aspects  of 
the  tissues  will  always  prevent  mistakes  of  this  sort. 

Intra- Abdominal  Manipulations. — During  the  various  procedures 
necessary  for  the  removal  of  an  abdominal  growth,  every  effort 
must  be  made  to  protect,  and  keep  out  of  the  way,  the  intestines. 


74  OPERATIVE  SURGERY  OF  ABDOMEN. 

Sponges  of  suitable  size  and  shape  are  packed  in  wherever 
bowels  appear,  and  the  growth  is  isolated  from  the  rest  of  the 
abdominal  contents  as  far  as  the  available  space  will  permit. 
By  means  of  sponge-packing  we  seek,  in  fact,  to  make  the 
manipulations  necessary  for  removal  as  nearly  extra-abdominal 
as  possible.  Wherever  we  can,  we  work  against  or  upon  sponges, 
and  not  against  boAvel  or  upon  peritoneum. 

Sponges  not  only  protect  delicate  organs  ;  they  absorb  and 
gather  up  any  blood  and  fluid  that  may  escape.  And  every 
spongeful  of  fluid  so  removed  is  a  saving  of  time  and  trouble 
against  the  time  when  it  becomes  necessary  to  perform  the  final 
toilet  of  the  peritoneum.  Whenever  a  sponge  appears  to  be 
saturated,  it  ought  to  be  replaced  by  one  that  has  been  squeezed 
dr3\  Of  course,  it  must  be  taken  out  of  fluid  that  is  warm  : 
carbolic  lotion,  of  the  strength  of  two  and  a  half  per  cent.,  is 
as  suitable  a  fluid  for  sponges  as  any. 

Most  of  the  difficulties  in  removing  abdominal  tumours  arise 
from  the  separation  and  management  of  adhesions.  When  they 
are  visible,  or  within  easy  reach  of  the  fingers,  their  separation 
may  be  comparatively  easy  ;  when  they  lie  deep,  or  out  of 
sight,  their  division  may  be  attended  with  difficulty  or  danger. 
Special  difficulties  arise  when  delicate  organs  are  glued  to  thin 
or  inflamed  walls  of  cystic  growths,  or  where  bowels  are  em- 
bedded in  sulci  of  the  tumour,  or  where  an}^  of  the  large 
abdominal  vessels  or  the  ureters  are  in  close  contiguity.  Ad- 
hesions to  the  omentum  are,  as  a  rule,  most  easily  dealt  with  ; 
adhesions  to  the  bowels  in  the  pelvis,  or  to  the  under  surface  ot 
the  liver  or  diaphragm,  are  among  the  most  difficult  of  all. 
Tumours  in  the  broad  ligaments  may  require  a  prolonged  and 
tedious  dissection  to  separate  them  from  uterus  and  bladder. 
Each  case  has  its  own  variety  of  adhesion,  which  must  be  dealt 
with  by  methods  peculiar  to  itself. 

Forceps,  sponges,  fingers,  scissors,  and  ligatures  are  in 
constant  use  during  the  surgical  management  of  adhesions. 
Slight  adhesions  are  best  separated  by  means  of  a  sponge ;  the 
adherent  organ  is  sponged  off"  the  tumour,  so  to  speak.  At 
every  step,  bleeding  points  are  looked  for,  and  forceps  placed  on 


SEPARATION   OF  ADHESIONS. 


75 


them  Adhesions  of  some  de- 
gree of  firmness,  if  broad,  must 
be  separated  by  fingers  :  if  long 
or  thin,  or  of  the  bulk  that  might 
be  classed  as  bands,  they  are 
divided  b}^  scissors  between 
pairs  of  catch-forceps.  Very 
dense,  broad,  and  sessile  adhe- 
sions are  divided  by  scissors ; 
while  forceps  or  ligature,  as  may 
seem  most  suitable,  checks  the 
bleeding  as  it  arises. 

The  best  form  of  forceps  for 
adhesions  is,  I  think,  Tait's 
modification  of  Koeberle's  in- 


FiG.  6. 

Tait's  modification  of  Koeberle's  Catch 
Forceps.     Two-thirds  size. 

strument.  (Fig.  6.)  But  Wells's  in- 
strument is  almost  equally  good,  and 
surgeons  who  ma)'  have  become 
accustomed  to  its  use  will  desire 
none  better.  The  advantage  that 
Tait's  forceps  possesses  is  in  its 
sharp  points,  which  can  scarcely 
be  included  in  the  ligature.  Both 
instruments  are  superior  to  Pean's 
older  forceps,  in  being  much 
stronger,  smaller,  and  more  easily 
handled.  These  instruments  are  so 
well  known,  being  in  the  hands  of  '   '' 

almost  every  operating  surgeon,  that     ^^'(^^^'^  Large  Pressure 
,,.,,,  .      .        .  Hades  bent  at  obtuse 

detailed  description  is  unnecessary.  „     tl'  d  '  e 


Forceps, 
anele. 


76 


OPERATIVE  SURGERY  OF  ABDOMEN. 


Besides  these  straight  small  forceps,  others,  bent  at  various 
angles  (Figs.  7  &  8),  or  T-shaped  (Thornton's,  Fig.  9)  and  of 
larger  size,  will  be  constantly  found  of  use.  Wells's  large  forceps 
(Fig.  10),  on  the  same  plan  as  his  small  one,  is  invaluable  for 
many  purposes.  Straight  forceps  of  medium  size  are  very  useful. 
I  have  invented  an  instrument  which  combines  cutting  with 
crushing,  and  which  I  have 
found  of  benefit  in  giving  a 
bloodless  division  of  thin 
flat  adhesions.  A  knife  is 
concealed  in  the  powerful 
blades  of  a  compression 
forceps,  and  divides  the 
adhesion  between  the  lines 
of  crushing.  (Fig.  11.)  A 
very  large  and  powerful 
T-shaped  forceps  I  have 
found  very  valuable 
Special  instruments  are 
necessar}'  for  special  oper- 
ations: these  will  be 
described  in  their  proper 
places. 

At  the  end  of  a  difficult 
operation,  as  man}^  as  two 
or  three  dozens  of  catch 
forceps  may  be  clinging  at 
points  where  bleeding  had 
taken  place.  By  many 
surgeons  it  is  considered 
necessary  to  apply  a  liga- 
ture to  each  of  these,  and  the  time  spent  in  doing  so  is  of 
necessity  very  considerable.  I  have  always  acted  upon  the 
principles  of  general  surgery,  regarding  a  small  bleeding 
point  which  has  been  effectually  compressed  as  secured  against 
haemorrhage.  Less  than  a  fourth  of  the  vessels  compressed  by 
forceps  require  ligature.     Most  of  them  will  have  been  crushed; 


Fig.  8. 

Wells's  Large  Pressure  Forceps,  blades  bent 
at  right  angle.     Half  size. 


TOILET  OF  PERITONEUM. 


77 


Fig.  9. 

Thornton's  T-shaped  Pressure  Forceps, 
Large  size.     Half  size. 

Toilet  of  the  Peritoneum. — Of  the 
many  good  practices  which  Keith 
has  introduced  into  abdominal  sur- 
gery, not  the  least  valuable  is  that 
of  removing  from  the  cavity  all 
blood  and  escaped  fluids  before 
closing  the  parietal  wound.  Most 
of  such  foreign  matter,  if  fluid,  will 
be  removed  with  the  sponges  placed 
in  the  cavity  during  operation.  A 
final  cleansing  by  means  of  a  sponge 
held  between  the  blades  of  a  sponge- 
holder    (Fig.    12)  and    carried    into 


and  on  many  of  them  the 
forceps  will  have  been 
hanging  for  ten  minutes 
or  a  quarter  of  an  hour, 
so  that  coagulation  will 
probably  have  taken 
place  above  the  crushed 
point.  I  am  convinced 
that  we  overdo  the  deli- 
gation  of  adhesions :  I 
believe  that  perfectly 
trustworthy  haemostasis 
may,  in  the  great  ma- 
jority of  bleeding  points 
left  after  separation  of 
adhesions,  be  effected  by 
forcipressure  alone. 


Fig.  10. 

WeUs's  Large  Pressure  Forceps. 
One-third  size. 


78 


OPERATIVE   SURGERY   OF  ABDOMEN. 


Douglas's  pouch  and  into  each  loin,  may  suffice.  But  if 
purulent  or  colloid  fluids,  or  the  contents  of  a  dermoid  cj-st, 
or,  generally,  any  materials  which  cannot  easily  be  removed 
by  a  sponge  after  moderate  use  of  it,  lie  in  the  cavity,  then 
Tait's  plan  of  washing  out  the  abdomen  ought  to  be  adopted. 
If  a  tumour  has  been  removed,  and  the  parietes,  being  relaxed, 


\   - 


Fig.  II. 

The  Author's  Scissors-clamp. 


Fig.  12. 

Sfonge-holding  Forceps.     One-third  size. 


can  be  pulled  forward,  the  cleansing  fluid  may  be  poured  in 
from  a  jug.  But,  for  most  cases,  irrigation  is  the  best  mode  of 
cleansing.  If  a  special  irrigating  apparatus  is  not  at  hand,  the 
fluid  may  be  conducted  from  an  ordinary  basin  by  arranging 
the  tubing  of  an  ordinary  trocar  as  a  siphon. 

For  conducting  the  irrigating  fluid  inside  the  abdomen,  I 


IRRIGATION   OF  CAVITY.  79 

have  had  made  simple  glass  tubes  of  different  sizes  at  the 
nozzle,  according  to  the  size  of  the  stream  we  may  wish  to 
employ,  but  all  of  one  size  at  the  other  end,  so  that  they  may 
fit  into  the  large  rubber  tubing  attached  to  Tait's  trocar.  Tait's 
trocar  used  at  the  end  of  the  rubber  tube  has  this  disadvantage 
in  cases  where  it  is  desirable  to  direct  the  stream  upon  a  certain 
small  area,  that  the  fluid  flows  out  through  two  openings  near 
the  point,  and  not  through  one  opening  at  the  point.  Some- 
times it  is  desirable  to  direct  a  small  stream  with  considerable 
force  upon  a  very  limited  area,  then  a  small  nozzle  may  be  used 
and  the  irrigating  reservoir  elevated  :  at  other  times  it  is  desir- 
able gently  to  fill  the  cavity  with  a  large  body  of  Avater,  then 
the  largest  nozzle  is  used  with  moderate  elevation.  The  size  of 
the  stream  and  the  force  of  it  can  thus  easily  be  regulated. 

To  aid  in  the  removal  of  particles  of  filth,  the  bowels  are 
moved  about  by  the  fingers,  and  the  abdominal  walls  are  gently 
kneaded  and  squeezed.  The  amount  of  foreign  matter,  such  as 
little  clots  of  blood,  small  shreds  of  tissue,  and  pieces  of  coag- 
ulated fibrine,  which  may  escape  from  the  abdomen  during 
irrigation,  is  sometimes  truly  surprising.  A  conspicuous  advan- 
tage of  irrigation  is,  that  it  will  always  make  visible  the  existence 
of  bleeding.  A  very  small  quantity  of  fresh  blood  makes  itself 
apparent  in  water. 

The  residual  fluid  left  after  squeezing  the  parietes  is  removed 
by  sponges.  It  is  often  a  good  practice  to  place  a  large  sponge 
in  Douglas's  pouch,  with  forceps  attached,  and  leave  it  there 
till  the  sutures  are  placed.  Fluid  is  attracted  to  a  sponge  from 
all  parts  of  the  abdomen,  except  perhaps  from  the  lumbar  hol- 
lows, and  sometimes  it  may  be  advisable  to  place  sponges  there 
also.  After  irrigation,  elaborate  sponging  is  not  required  ;  the 
fluid  which  remains  after  squeezing  the  parietes  is  quietly  soaked 
up  by  the  sponge  or  sponges  left  inside  while  the  sutures  are 
being  inserted.  A  few  ounces  of  clear  fluid  left  inside  do  no 
harm  whatever  ;  indeed,  it  is  conceivable  that  under  certain 
circumstances  such  fluid  may  do  good.  In  four  cases  where 
I  employed  irrigation,  after  re-opening  the  abdomen  for  peri- 
tonitis following  operation,  I  did  not  attempt  to  suck  out  an}-  of 


so  OPERATIVE   SURGERY  OF  ABDOMEN. 

the  fluid,  but  simpl}'  let  it  flow  away  through  a  drainage  tube. 
Sometimes  as  much  as  a  pint  would  be  left  inside,  and  very 
Jittle  of  this  would  come  away  in  the  next  twenty-four  hours. 
All  the  patients  recovered.  In  most  cases  where  irrigation  has 
"been  called  for,  a  drainage  tube  will  be  inserted,  and  left  in  for 
at  least  one  day. 

Before  the  parietal  wound  is  closed,  all  sponges  and  instru- 
ments are  counted,  to  make  sure  that  nothing  has  been  left 
inside  the  cavit}'.  Judging  from  the  number  of  catastrophes 
which  have  been  caused  by  leaving  foreign  bodies  in  the  abdo- 
men, the  necessity  of  doing  this  would  seem  to  be  very  real. 
Dr.  Wilson'''  has  collected  twenty-one  such  cases,  in  most  of 
which  the  foreign  bod}^  was  a  whole  sponge  or  part  of  one, 
and  in  a  minorit}^  forceps.  It  is  a  good  rule  always  to  begin 
operation  with  a  fixed  and  definite  number  of  sponges  and 
instruments. 

Drainage. — The  wounded  or  irritated  peritoneum  secretes 
fluid  in  amount  varying  according  to  the  extent  of  the  trau- 
n:iatism.  Sero-sanguineous  oozing  from  raw  surfaces  adds  to 
the  exudations.  The  peritoneum,  in  its  healthy  regions,  has  a 
great  power  of  absorption,  and  in  most  cases  these  fluids  are 
absorbed  as  rapidly  as  they  are  secreted.  But  sometimes  secre- 
tion is  too  rapid  for  absorption,  and  we  then  get  a  collection  of 
fluid  which  has  a  tendency  to  gravitate  into  Douglas's  pouch. 
This  fluid  is  peculiarl}'  liable  to  undergo  decomposition — 
usually,  no  doubt,  from  septic  influences  introduced  from  the 
outside;  but  occasionally,  I  believe,  from  contamination  through 
the  coats  of  the  large  bowel.  In  an}'^  case,  the  accumulation  of 
fluid  in  the  pelvis  after  abdominal  operations  is  a  thing  to  be 
guarded  against.  If  we  have  any  apprehension  that  the  amount 
exuded  will  be  considerable,  we  ought  to  drain  ;  and  in  any 
case  of  doubt,  it  is  wise  to  drain.  While  bleeding  is  going  on, 
the  tube  should  not  be  removed ;  and  if  bleeding  is  appre- 
hended, the  tube  should  be  inserted  and  left  till  the  danger  has 
passed.  Whenever  purulent  or  decomposing  fluid  has  escaped 
into  the  abdominal  cavity,  drainage  should  be  employed.  It  is 
*  Trans,  of  Ameiican  Gyito'C.  Soc.  vol.  ix. 


DRAINAGE   TUBES. 


ai 


said  that,  the  older  the  patient  is,  the  less  is  absorption  by  the 
peritoneum,  and  therefore  the  greater  the  necessity  for  draining. 
The  special  indications  for  drainage  in  special  operations  will 
be  named  further  on. 

The  best  drainage  tubes  for  general  use  are  Keith's  modifi- 
cation of  Koeberle's.  (Fig.  13.)  They  are  glass  tubes,  open  at 
both  ends,  with  several  perforations  near 
the  end  of  the  tube  which  is  inserted  into 
the  cavity,  and  a  protruding  lip  near  the 
outer  extremity  where  it  passes  through  the 
wound.  The  intra-abdominal  pressure  being 
greater  than  that  of  the  outer  air,  most  of 
the  fluid  will  escape  through  any  opening 
provided.  A  tube  perforated  through  all  its 
length  may  permit  some  of  the  fluid,  as  it 
rises  from  the  pelvis,  to  escape  amongst  the 
bowels  and,  if  this  fluid  is  decomposing, 
to  infect  an  amount  of  peritoneal  surface 
greater  than  necessary. 

It   is   necessary   to   be  certain   that   the 
tube  is  pervious,  and  that  it  is  in  the  midst 
of  the  fluid.      It    may    become  blocked    by 
Fig.  i^.  clotting    of    the   discharges;    this    may    be 

rr  :,,    ^,       r,    ■         guarded  against  by  using  a  syringe  or  suc- 
Ketth's  Glass  Drainage    °  *=  j  o         J        & 

Tube.  Half  size.  tion  instrument.  Pieces  of  bowel  may  be 
drawn  into  the  openings,  and  so  prevent  the 
entrance  of  fluid :  pulling  the  tube  out  a  little  way,  and  rotating 
it,  will  put  this  right.  The  fluids  may  be  very  thick,  becoming 
colloid  or  even  clotted,  and  then  it  will  be  necessary  to  use  an 
exhausting  syringe.  The  little  apparatus  of  Tait  (Fig.  14)  is 
very  efficient  for  this  purpose.  It  is  essentially  a  rubber  bag 
attached  to  the  end  of  a  piece  of  glass  tubing.  To  the  side  of 
the  tube  is  attached  a  glass  globe,  into  which  the  extracted 
fluid  falls ;  to  the  free  extremity  is  attached  a  piece  of  rubber 
tubing,  small  enough  to  pass  down  the  drainage  tube.  The 
tube  is  inserted  while  the  bag  is  empty ;  as  the  bag  expands, 
the  fluids  are  sucked  up. 

7 


82 


OPERATIVE  SURGERY  OF  ABDOMEN. 


In  cases  where  there  is  bleeding,  it  is  a  golden  rule  to  keep 
the  abdomen  dry.  This  may  be  done  by  the  frequent  use  of 
the  exhausting  syringe — every  few  minutes  or  every  few  hours, 
according  to  the  case.  No  doubt  the  efficacy  of  this  plan 
depends   to   some   extent   on   the   removal   of  secreted   serous 

fluid,  which  would  dissolve  up 
the  blood-clot.  Just  as  bleeding 
js  encouraged  after  leech  -  bites 
by  the  application  of  hot  wet 
cloths,  so  it  is 
encouraged  after 
division  of  ves- 
sels in  the  ab- 
dominal cavity 
by  their  being 
bathed  in  abun- 
dant thin  serous 
fluid.  Keeping 
the  abdomen  dry 
permits  clotting, 
and  thereby  pro- 
motes haemosta- 


sis. 


Fig.  15. 


Koeberle's  Glass 

Drainage  Tube.    Half 

size. 


Fig.  14. 
TaiVs  Exhausting  Syringe. 


For  the  drain- 
age of  simple 
serous  fluids,  a 
tube  on  the  plan 

of  Koeberle's  original  one  is  best. 
This  is  essentially  an  ordinary 
test  tube,  with  numerous  perforations  along  its  whole  length. 
Koeberle's  tube  is  slightly  conical,  and  this  shape  renders 
it  liable  to  slip  out  of  the  opening:  in  the  tube  shown 
in  the  engraving  (Fig.  15)  the  neck  is  the  narrowest  point,  and 
escape  from  the  cavity  is  thereby  prevented.  The  bulbous 
end  brings  a  larger  surface  of  intestine  into  contact  with  it, 
which  is  perhaps  an  advantage.  Tait  has  recently  recom- 
mended a  tube  which  is  cylindrical,  exactly  Hke  a  test-tube. 


DRAINAGE.  83 

The  rounded  extremity  of  the  tubes  on  Koeberle's  plan  is  less 
likely  to  cause  perforation  of  the  rectum  than  the  annular 
extremity  of  Keith's  tubes.  Its  numerous  perforations  are  an 
advantage  in  draining  abundant  ffuid,  and  no  disadvantage  if 
the  fluid  is  not  septic.  Keith's  tube,  on  the  other  hand,  has  the 
enormous  advantage  of  permitting  the  extraction  of  pieces  of 
clot,  or  lymph,  or  other  aggregated  material. 

Drainage  of  fluid  may  be  promoted  by  capillary  action.  A 
shred  of  gauze  rolled  up  and  laid  in  the  tube,  serves  this  pur- 
pose admirably.  The  free  end  of  the  roll  of  gauze  is  placed  in 
contact  with  the  absorbent  dressing,  or  sponge,  which  is  laid 
over  the  end  of  the  tube.  This  simple  expedient,  which  I  have 
always  employed  inside  a  drainage  tube,  has  recently,  under  the 
name  of  capillary  drainage,  been  extolled  as  a  novel  and  highly 
valuable  method  *  with  the  threads  free  inside  the  abdominal 
cavity.  By  capillary  action  the  abdomen  can  be  kept  continuously 
dry :  the  exhausting  syringe  acts  only  intermittently,  and  the 
fluids  collect  in  the  intervals.  The  full  advantage  of  the  plan 
may  be  got  by  placing  the  threads  inside  the  drainage  tube :  it 
unnecessarily  adds  to  peritoneal  irritation  to  let  the  threads  lie 
loose  inside  the  cavity. 

The  manner  of  collecting  and  removing  the  discharges  from 
the  drainage  tube  is  of  some  importance.  The  end  of  the  tube 
is  completely  isolated  by  a  square  of  rubber  cloth,  through  the 
centre  of  which  a  hole  has  been  cut,  large  enough,  with  a  little 
stretching,  to  encircle  the  tube  below  the  collar.  The  absorbent 
material  being  placed  over  the  end  of  the  tube,  the  cloth  is 
folded  over  it,  so  as  to  completely  envelope  the  dressing,  and 
the  whole  is  retained  in  position  by  a  loose  binder.  The  dressing 
is  changed  as  often  as  it  gets  nearly  saturated  by  simply  unfolding 
the  rubber,  and  without  disturbing  the  coverings  of  the  wound. 
Sponges  are  usually  employed  to  absorb  the  discharges  ;  but  the 
obvious  objections  to  the  use  of  sponges  for  this  purpose  make 
me  prefer  absorbent  wool  or  gauze.  Sal-alembroth  wool,  prop- 
erly prepared,  is  an  excellent  absorbing  material,  not  so  cumber- 
some as  sponges,  and  is,  besides,  a  powerful  antiseptic. 
*  Cf.  Pozzi,  Ann.  de  Gynec,  1888,  XXIX. 

7  * 


84  OPERATIVE  SURGERY  OF  ABDOMEN. 

Closing  the  Wound  in  the  Parietes. — When  the  time  has  come  for 
closing  the  cavity,  a  dry  sponge  of  convenient  size  is  placed  over 
the  bowels  under  the  opening.  This  keeps  the  bowels  out  of 
the  way  and  absorbs  the  blood  that  is  shed  by  the  needle  punc- 
tures. A  drachm  of  pure  blood  can  usually  be  squeezed  from 
this  sponge  after  inserting  sutures  in  a  wound  three  or  four 
inches  long. 

Many  plans  of  suturing  the  abdominal  wound  are  in  vogue. 
Some  surgeons  use  two  or  three  silver  tension-sutures  through 
muscle  and  peritoneum,  and  close  the  rest  of  the  wound  by 
superficial  sutures.  I  had  used  this  plan  in  a  good  few  cases, 
finding  it  answer  admirably,  till  I  had  a  bronchitic  patient, 
whose  constant  coughing  caused  the  silver  sutures  to  partly  cut 
their  way  through ;  and  then  I  abandoned  it.  The  best  mode 
of  suturing  the  wound  is,  I  believe,  by  interrupted  silk  or  silk- 
worm gut  sutures  placed,  about  three  to  the  inch,  close  to 
the  margins  of  the  wound,  and  every  one  including  perito- 
neum. In  these  sutures  some  surgeons  are  careful  to  include 
only  skin,  fascia,  and  peritoneum ;  others  include  muscle 
as  well.  I  matters  little,  as  regards  immediate  union,  what 
tissues  are  included  in  the  suture  ;  but  it  is  important  to  provide 
against  the  remote  risks  of  a  ventral  hernia,  by  having  as  broad 
a  basis  of  union  as  possible.  After  a  few  months  all  uniting 
cicatricial  tissue  becomes  lax  and  distensile;  the  more  that 
there  is  of  it,  the  stronger  will  it  be.  I,  therefore,  always  push 
the  needle  straight  through  everything,  at  the  same  distance 
from  the  surface  in  muscle  and  in  peritoneum  as  in  skin. 
When  the  sutures  are  tied,  the  line  of  incision  then  bulges  out- 
wards; when  only  skin,  fascia,  and  peritoneum  are  included,  the 
sutured  wound  appears  depressed. 

Many  surgeons  close  the  wound  by  means  of  individual 
sutures,  to  each  end  of  which  a  needle  is  attached.  Keith  uses 
a  peculiarly  fine  straight  needle ;  others  use  an  ordinary  long 
glover's  needle.  For  some  time  past  I  have  used  a  suture 
instrument  (Fig.  i6)  with  needles  made  on  Hagedorn's  plan, 
but  with  much  shorter  cutting  points,  and  I  have  found  it 
exceedingly  convenient    for   the   purpose.      It   is  essentially  a 


SUTURING    THE  PARIETAL   WOUND. 


85 


handled  needle,  the  handle  of  which  contains  a  reel  on  which 
the  suture  silk  is  wound ;  and  it  may  also  contain  lotion  in 
which  the  thread  is  soaked.  With  this  instrument,  after  a  little 
practice,  sutures  may  be  inserted  with  much  greater  rapidity 
and  precision  than  with  the  ordinary 
needle.  It  also  saves  the  trouble  of 
threading  and  otherwise  looking  after 
numerous  needles  and  sutures.  The  end 
of  the  handle  is  large  enough  to  contain 
the  ordinary  trade  reel  of  plaited  silk, 
and  the  thread  runs  through  the  cavity  of 
the  handle,  which  contains  lotion,  to  the 
end  of  the  needle.  While  the  bulbous  end, 
containing  the  reel,  lies  in  the  hollow  of 
the  palm,  the  tips  of  the  fingers  rest  at  the 
end  near  the  needle,  and  manipulation  is 
easy  and  comfortable.  The  needle  may 
be  inserted  in  the  axis  of  the  handle,  or 
at  right  angles  to  it ;  and  various  sizes  of 
needles  may  be  used  for  different  thick- 
nesses of  the  abdominal  walls. 

The  needle  is  made  to  transfix  skin, 
fascia,  muscle,  and  peritoneum  on  the 
right  side  of  the  wound ;  and  then  peri- 
toneum, muscle,  fascia,  and  skin  on  the  left 
side ;  the  loop  of  thread  is  caught  in  the 

finger,  the  free  end  drawn  out,  the  needle  Suture  Instyument.    Half 
withdrawn,    and   the   sutures    cut,    each  ^''^''• 

about  six  or  eight  inches  long,  and  their  ends  handed  over  to  an 
assistant.  About  three  sutures  to  an  inch  is  a  fair  proportion. 
When  all  the  sutures  are  inserted,  the  sponge  is  removed,  the 
suture  threads  are  tied,  and  the  ends  cut  off.  If  the  stitches 
are  neatly  inserted,  the  whole  length  of  the  wound  will  be 
perfectly  and  accurately  closed,  and  no  secondary  or  superficial 
sutures  are  necessary. 

For  placing  silk-worm  gut  sutures,  which  I  now  use  to  the 
exclusion  of  all  others  in  abdominal  operations,  I  employ  the 


Fig.   i6. 

The  Author's 


86  OPERATIVE  SURGERY  OF  ABDOMEN. 

same  needle.  The  needle  is  passed  unthreaded,  the  gut  is 
pushed  through  the  eye  of  the  needle  and  pulled  through  the 
tissues  as  the  needle  is  withdrawn.  As  the  eye  of  the  needle  is 
large  and  gut  is  a  material  Very  easily  threaded,  this  manceuvre 
can  be  carried  out  with  great  ease.  The  assistant,  holding  a 
bundle  of  sutures  in  his  hand,  may  thread  the  needle  each  time 
it  is  passed, 

Hagedorn's  needle  and  holder  are  employed  by  several  well- 
known  surgeons.  I  have  used  it  somewhat  extensively  in 
general  surgery,  and  like  it  for  many  purposes.  In  suturing  very 
thick  parietes  the  long,  straight  needle  supplied  in  Hagedorn's 
set,  and  passed  by  means  of  his  holder,  will  be  found  very  use- 
ful. But  for  general  use  in  suturing  the  abdomen  I  consider  the 
handled  needle  most  convenient.  In  very  short  wounds,  such 
as  one  made  in  uncomplicated  ovariotomies,  three  or  four 
stitches  may  be  all  that  are  required,  and  then  it  matters  very 
little  what  needles  are  employed. 

Dressings. — In  a  few  hours  after  operation  the  peritoneal 
surfaces  will  have  united,  and  the  parietal  wound  will  then  be, 
to  all  intents  and  purposes,  a  superficial  one.  It  matters  very 
little  what  the  dressing  is,  if  it  is  unirritating  and  absorbent.  A 
pad  of  alembroth  wool,  or  salicylic  silk,  or  carbolised  gauze,  or 
a  few  folds  of  boracic  lint,  will  serve  the  purpose  admirably. 
The  dressing  need  not  be  disturbed  for  a  week,  when  the  wound 
will  be  found  quite  healed,  and  the  stitches  may  be  removed. 
On  the  dressing,  when  removed,  we  expect  to  find  a  thin  la3'er 
of  dried  sero-sanguinolent  discharge,  two  inches  broad. 

After  removal  of  a  large  tumour,  I  think  the  plan  of  covering 
the  whole  abdomen  with  long  broad  layers  of  strapping  should 
be  adopted.  The  sudden  decrease  of  abdominal  tension  that 
follows  removal  of  an  abdominal  tumour  no  doubt  favours 
gaseous  distension  of  the  bowels  ;  and  strapping  is  undoubtedly 
a  better  means  of  preventing  this  than  a  tight  binder.  The 
strips  of  plaster  act  as  a  firm  unyielding  splint,  keeping  the 
parts  immovable,  and  permitting  the  patient  whatever  liberty  of 
movement  she  may  desire.  Not  only  are  changes  of  position 
from  the  back  to  the  side  very  agreeable  to  the  patient ;    but 


GENERAL   CONSIDERATIONS.  87 

lying  on  the  side,  with  the  knees  drawn  up,  favours  the  passage 
of  flatus  and  the  use  of  the  rectum-tube.  Hollows  under  the 
strapping  are  to  be  filled  up  by  firm  pads  of  some  sort ;  folded 
towels  do  very  well.     A  binder  is  unnecessary. 

If  drainage  is  used,  the  dressing  and  strapping  stop  short  at 
the  point  where  the  tube  emerges.  Special  dressings  are 
arranged  around  the  end  of  the  tube  in  the  manner  already 
described  (p.  83).  The  most  scrupulous  attention  ought  to  be 
paid  to  the  securing  of  perfect  cleanliness  in  the  means  adopted 
for  collecting  discharges  from  the  abdomen. 

Stitch-abscesses,  causing  some  elevation  of  temperature, 
are  mentioned  as  possible  accidents  during  the  uniting  of  the 
parietal  wound.  Those  are  never  seen  in  wounds  treated  anti- 
septically,  and  I  think  they  can  be  caused  only  by  the  use  of 
sutures  that  are  not  absolutely  free  from  filth.  Perhaps  too 
much  tension  in  the  stitches  might  cause  suppuration  in  their 
track ;  but  if  everything  were  aseptic,  this  would  not  cause 
much  elevation  of  temperature. 

In  the  manipulative  part  of  the  operation,  absolute  precision 
and  exactitude,  as  far  as  hands  and  materials  can  secure  these, 
are  necessary  to  the  most  perfect  success.  Not  only  must  no 
part  of  the  work  be  hurried  over  or  scamped,  but  every  detail 
must  be  finished  and  rounded  off  with  a  thoroughness  as  minute 
and  genuine  as  if  that  detail  were  the  turning  point  of  success. 
And,  practically,  it  is  a  fact  that  imperfect  attention  to  almost 
any  detail  may  result  in  a  catastrophe. 

But  the  avoidance  of  bungling,  oversight,  or  neglect  is  not 
enough.  It  is  possible  to  overdo,  as  well  as  to  underdo.  The 
clamp  is  an  example  of  overdoing,  and  the  calamities  that 
followed  its  use  are  our  warning.  We  may  run  to  excess  in 
the  means  adopted  for  stemming  haemorrhage,  by  means  other 
than  the  clamp.  We  see  this  in  the  double,  triple,  or  even 
quadruple  ligation  of  the  most  ordinary  pedicles  by  certain 
operators ;  in  an  elaborate  sponging  of  the  peritoneal  cavity, 
that  is  prolonged  beyond  cleansing  into  irritation ;  in  separate 
suturing  of  peritoneal  surfaces ;  and  in  many  other  ways  that 
could  be  mentioned. 


88  OPERATIVE   SURGERY  OF  ABDOMEN. 

It  must   not   be  forgotten   that   shock  is  one  of  the  chief 
dangers   in   all   abdominal   operations,    and   that    tardiness   in 
operating  is  an  important   factor  in  contributing  thereto.     In 
addition  to  the  risk  from  extended  traumatism,  we  must  reckon 
with  that  from  prolonged  anaesthesia.     These  propositions  have 
only  to  be  stated,  to  be  admitted ;  but  not  all  who  admit  them 
act  upon  them.     Rapidity  in  operating  is  a  prime  virtue  in 
abdominal   surgery;   but   this  rapidity  must    specially  be  cul- 
tivated over  the   more  subsidiary  details,    as   in   making   the 
parietal  wound  and  closing  it.     In  other  matters  no  time  must 
be  spent  in  deliberating.     The  surgeon  must  be  prepared  with 
mind,  hand,   and  instrument,   to  meet  every  emergency  as  it 
arises   according   to   the   best   rules  of  his    art.     A  man  who 
enters  the  abdominal  cavity  ought  to  be  able  to  do  anything, 
from  ligature  of  a  vessel  to  resection  of  the  intestine ;  and  he 
should  be  prepared  to  do  this  in  a  manner  which  defies  the  criti- 
cism of  his  brethren.    We  can  rarely  diagnose  perfectly  the  state 
of  matters  inside  an  abdomen  before  we  open  it,  and  we  ought 
therefore  to  be  able  to  treat  anything  which  we  find  when  we  enter. 
Dexterity  here  comes  from  knowledge  as  much  as  from  practice. 
To  be  prepared,  at  the  appearance  of  any  complication,  to 
apply  the  best  known  surgical  technics ;  to  do  what  is  wanted, 
and  no  more  than  is  wanted ;  to  have  the  manner  and  method 
of  each  procedure  mentally  laid  down  in  clear  and  definite  lines  ; 
and   generally   to   perform   the   operation   in    steady,  straight- 
forward, workmanlike  manner  through  the  endless  complications 
that  may  arise,  is  ho  trifling  call  on  the  capacities  of  a  human 
being.     Much  of  it  may  be  learnt  by  intelligent  practice,  at  the 
expense  of  the  patients ;  much  may  be  learnt  by  careful  study 
and  practice  on  the  dead  body  ;  but  most  of  all  will  the  young 
surgeon  derive  information  from  a  close  and  intelligent  personal 
attendance  at  the  operations  of  our  great  masters.     Abdominal 
surgery  is  no  longer  a  field  for  legitimate  and  versatile  experi- 
ment;  certain  fixed  and  useful  laws  and  customs  have  been 
laid  down  by  the  dearly  bought  experience  of  great  men :  the 
abdominal  surgeon  ought  to  begin  fully  equipped  with    such 
knowledge  as  has  been  gathered  for  him. 


After-Treatment  of  Cases  of  Abdominal  Operation. 

A  golden  rule  in  the  treatment  of  cases  of  laparotomy  is — 
to  let  the  patient  alone.  Everything  approaching  to  meddle- 
someness is  to  be  condemned.  The  patient  must  not  be  upset  by 
fussy  applications  of  tentative  therapeutics  :  when  an  emergency 
arises,  it  is  to  be  met,  promptly  and  decisively,  by  a  method 
which  has  been  approved  trustworthy. 

Comfort  may  be  regarded  as  a  therapeutic  measure  of  some 
importance.  Besides  the  ordinary  measures  that  would  be 
adopted  with  a  patient  who  is  seriously  ill,  certain  minor  atten- 
tions in  abdominal  cases  may  be  carried  out  with  benefit.  The 
luxury  of  a  change  into  a  second  bed,  with  clean  fresh  linen, 
will  be  highly  appreciated,  and  will  often  be  a  means  of  securing 
a  good  night's  rest.  Changes  of  position — moving  the  patient 
from  back  to  side,  raising  the  head  and  shoulders  a  little,  bending 
the  knees  over  pillows,  or  raising  the  lower  limbs  on  supports — 
all  tend  to  lessen  the  irksomeness  of  confinement  to  bed,  and  by 
so  much  to  increase  the  chances  of  recovery.  Sponging  the  arms, 
legs,  and  chest,  or  washing  them  with  soap  and  warm  water, 
will  always  be  grateful.  These  and  similar  proceedings  are  well 
worthy  of  consideration,  as  being  itemxS  in  the  not  inconsiderable 
total  of  the  patient's  comfort. 

As  to  the  administration  of  food  and  drink  to  the  patient,  it 
is  impossible  to  give  definite  rules.  Generally  speaking,  the 
gravity  of  the  case,  and  our  apprehension  of  danger,  will  be  our 
guides.  A  simple  case  of  oophorectomy  or  ovariotomy,  after  the 
first  twenty-four  hours,  will  require  little  change  from  the  ordin- 
ary diet  of  health.  In  cases  of  serious  operation,  where  some 
■degree  of  inflammation  of  injured  viscera  is  bound  to  supervene, 
dieting  may  be  of  supreme  importance.  In  such  cases  irritability 
of  the  whole  digestive  tract,  with  vomiting  and  tympanites,  may 
co-exist  with  an  urgent  necessity  for  supporting  the  patient's 
strength  by  stimulating  nourishment.  The  judicious  manage- 
ment of  these  cases  will  tax  the  surgeon's  capacity  to  the 
utmost. 

In  general,  milk  is  a  bad  food  for  abdominal  cases.     It  is  not 


90  TREATMENT  AFTER   ABDOMINAL   OPERATIONS. 

digested  by  the  stomach,  and,  as  curd,  it  may  pass  a  long  way- 
down  the  intestine;  also,  it  is  a  food  that  causes  flatulence. 
Peptonised  milk  has  not  these  drawbacks,  but  patients  rarely 
like  it.  Good  home-made  beef  tea,  or  any  of  the  numerous 
concentrated  beef  jellies,  taken  either  solid  in  tea-spoonfuls  at 
a  time,  or  much  diluted  if  the  patient  is  thirsty,  are  usually 
agreeable  to  the  patient,  and  are  of  great  value.  Oatmeal  gruel 
and  Hquid  arrowroot,  with  similar  articles  of  diet,  varied  accord- 
ing to  the  patient's  taste,  may  be  given. 

"  Little  and  often  "  is  to  be  the  rule  of  administration ;  but 
not  too  little  nor  too  often.  The  stomach,  like  other  organs, 
wants  occasional  rest ;  and  to  keep  it  in  constant  action  for 
three  or  four  days  on  end  by  hourly  or  half-hourly  exhibitions 
of  small  quantities  of  nourishment,  will  result  in  functional 
irritation,  or  even  exhaustion  of  the  organ.  The  peculiarities 
of  the  case,  and  the  tolerance  of  the  stomach,  must  direct  us. 
In  all  cases  we  must  not  forget  that  foods  when  peptonised  may 
be  retained  and  absorbed,  when  they  would  be  rejected  in  their 
unprepared  condition. 

As  a  rule,  in  cases  of  average  gravity,  it  will  be  found  a  wise 
plan  to  give  the  patient  only  warm  water,  or  toast-water,  by  the 
mouth  for  the  first  twenty-four  or  forty-eight  hours,  and  then 
begin  the  administration  of  foods  such  as  have  been  mentioned. 
Cold  water,  and  particularly  "  ice  to  suck,"  for  thirst,  are  to  be 
avoided :  the}^  do  not  allay  thirst  so  well  as  warm  water ;  and 
my  experience  coincides  with  that  of  others,  that  they  are  more 
commonly  rejected.  If  the  patient  complains  of  thirst,  a  pint 
of  tepid  water  slowly  administered  as  enema  will  rapidly  and 
effectually  alleviate  it.  It  is  unwise  to  upset  the  functional 
capacities  of  the  stomach  by  ingestion  of  large  quantities  of 
fluid  to  allay  thirst,  when  this  end  may  be  attained  by  rectal 
absorption. 

In  operations  upon  females,  special  attention  must  be  paid 
to  the  management  of  the  functions  of  the  bladder.  It  used  to  be 
considered  necessary  to  draw  off  the  water  by  catheter  at 
frequent  and  stated  intervals  for  some  days  after  operation. 
This  is  quite  unnecessary.    The  catheter  need  not  be  passed  till 


SHOCK  AFTER   OPERATION.  91 

the  patient  feels  a  desire  to  micturate ;  and  as  soon  as  she  can 
pass  water  herself,  she  may  be  permitted  to  do  so.  Some 
patients  do  not  require  the  use  of  the  catheter  at  all.  In  the 
first  twenty-four  hours,  the  secretion  of  urine  is  usually  scanty, 
and  the  instrument  may  not  have  to  be  used  at  all  in  this  time. 
In  few  cases  will  it  have  to  be  passed  oftener  than  thrice  in 
the  day. 

Cystitis,  often  of  a  troublesome  nature,  is  occasionally 
produced  by  catheterism.  To  avoid  this,  the  catheter  must 
be  cleansed  with  scrupulous  care ;  and  a  new  one  should  be 
provided  after  one  has  been  used  half-a-dozen  times.  A  male 
rubber  or  celluloid  catheter,  of  the  size  of  No.  6  or  8  English 
make,  is  the  best  instrument  to  use. 

The  above  account  refers  to  the  management  of  simple 
straightforward  cases  which  proceed  easily  and  rapidly  towards 
recovery.  But  sometimes  we  have  to  deal  with  conditions 
which  are  partly  outcomes  of  gravity  of  operation,  and  partly 
special  to  abdominal  cases.  Among  the  former  we  may  reckon 
shock  or  collapse,  restlessness,  and  pain ;  among  the  latter, 
vomiting,  tympanitic  distension,  and  peritonitis. 

Severe  shock  after  operation  is  treated  on  ordinary  surgical 
principles,  by  hot  bottles,  hot  blankets,  stimulating  applications 
to  the  epigastrium,  elevation  of  limbs,  and  so  forth.  Surrounding 
the  limbs  in  packs  wrung  out  of  hot  water  has  often  an  excellent 
effect.  Hypodermic  injections  of  ether,  ammonia,  or  brandy, 
and  rectal  injections  of  diffusive  and  alcoholic  stimulants,  are 
frequently  administered.  Gill  Wylie'''  speaks  highly  of  the 
value  of  irrigation  of  the  cavity  with  hot  water  (105° — 110'=* 
Fah.)  as  preventive  of  shock  ;  and  others  have  borne  testimony 
to  the  same  effect.  Restlessness  and  jactitation  must  be  treated 
by  a  hypodermic  injection  of  a  quarter  of  a  grain  of  morphia, 
to  be  followed  in  an  hour  by  a  sixth  of  a  grain  or  more,  accord- 
ing to  the  effect  of  the  first  dose.  Morphia  is  not  to  be  used 
unless  there  is  strong  necessity  for  it.  It  lowers  the  functional 
activity  of  the  intestines,  and  favours  the  production  of  tym- 
*  N.  Y.  Med.  Rec,  March  19th,  1887. 


92  TREATMENT  AFTER  ABDOMINAL   OPERATIONS. 

panites — an  effect  which  is  specially  to  be  avoided.  The  patient 
is  to  be  encouraged  to  bear  the  pain :  it  rarely  lasts  for  a  long 
time  ;  and  it  will  be  better  for  her,  in  the  event  of  further 
troubles  arising,  that  she  should  meet  them  with  a  system  unim- 
pregnated  with  morphia.  The  routine  employment  of  morphia 
is  to  be  condemned.  The  patient  is  always  brighter  and  better 
without  it,  if  there  is  no  urgent  call  for  its  exhibition. 

In  grave  cases  it  is  wise  to  begin  at  once  feeding  by  the 
rectum  in  the  manner  to  be  described.  Collapse  is  a  cause  of 
vomiting ;  and  want  of  food  and  stimulants  for  the  customary 
twenty-four  hours  may  encourage  the  very  symptoms  we  wish  to 
ward  off.  Free  stimulation,  by  brandy  or  other  spirit,  adminis- 
tered in  enema,  during  the  first  day  or  two  after  a  very  serious 
operation  on  a  weak  patient,  is  a  therapeutic  measure  of  supreme 
value.  In  many  cases  a  glass  of  hot  spirit  and  water,  taken 
the  last  thing  at  night,  will  act  as  a  soporific. 

Vomiting  is  perhaps  the  most  troublesome  single  symptom 
that  we  have  to  deal  with,  after  abdominal  operations.  Arising 
soon  after  operation,  and  lasting  over  ten  or  twenty  hours,  it 
may  be  nothing  more  than  an  effect  of  the  anaesthetic.  When 
it  exists  on  the  third  or  fourth  day,  and  continues,  we  may 
conclude  that  it  indicates  peritonitis  or  enteritis,  or  some  allied 
inflammatory  condition,  which  causes  paralysis  of  the  functions 
of  the  bowels.  In  this  case  we  must  take  prompt  measures  to 
deal  with  events  which  may  have  grave  issues. 

The  vomiting,  in  this  case,  is  not  the  sort  that  can  be 
controlled  by  medicine.  Indeed,  it  is  more  than  doubtful  if  it  is 
desirable  to  seek  to  control  it.  It  is  almost  uniformly  accom- 
panied by  distension  of  the  bowels  with  gas  and  fluid,  and 
vomiting  affords  relief.  It  is  certainly  not  wise  to  let  the  patient 
continue  feeling  sick  and  vomiting  frequently  small  quantities  at 
a  time ;  but  it  may  be  wise  to  encourage  free  vomiting  for  a  few 
minutes  together.  I  have  found  that  the  administration  of  as 
much  fluid  as  the  patient  will  drink — soda-water,  or  weak  tea, 
or  simple  warm  water — is  followed  by  the  evacuation  of  large 
quantities  of  bilious  fluid  and  gas,  and  makes  the  patient 
comfortable  for  some  hours.     In  more  than  one  bad  case,  I 


PERITONITIS.  93 

have  found  Kussmaul's  treatment  of  washing  out  the  stomach 
by  the  stomach  pump  of  conspicuous  benefit. 

The  indication  is  rather  to  remove  the  cause  of  the  vomiting, 
than  to  check  it  when  it  has  set  in.  For  this  end,  we  must  at 
once  stop  the  administration  of  everything  by  the  mouth,  and 
support  the  patient  entirely  by  rectal  feeding.  By  lying  on 
the  side,  and  wearing  the  rectum  tube  as  much  as  possible, 
the  passage  of  flatus  downwards  is  encouraged.  And  at 
least  once  a  day,  large  quantities  of  warm  water,  with  a  little 
turpentine,  are  injected  into  the  rectum,  so  as  to  completely 
remove  whatever  gas  may  be  in  the  large  bowel,  and  encourage 
more  of  it  to  descend  from  the  small  bowel. 

We  may  at  the  same  time  have  to  deal  with  peritonitis,  local 
or  general.  I  am  by  no  means  alone  in  believing  that  the 
administration  of  opium  is  not  always  the  best  treatment  for 
peritonitis.  Where  great  restlessness  accompanies  the  vomiting, 
opium — or,  better,  the  hypodermic  injection  of  morphia — may 
be  given  at  frequent  intervals  ;  but,  as  a  rule,  the  use  of  sedatives 
is  to  be  condemned.  Holding,  as  I  do,  that  the  tympanites 
which  accompanies  peritonitis  is  a  real  cause  of  obstruction,  and 
thereby  induces  vomiting,  I  have  for  some  years  been  in  the 
habit  of  cautiously  prescribing  a  saline  purge,  in  the  hopes  of 
carrying  off  this  flatulence.  The  results  were  beyond  expecta- 
tion, and  when  I  had  found  it  had  been  for  some  time  a  routine 
treatment  in  Tait's  practice,  I  had  no  hesitation  in  extending  it. 
A  purge  carries  off"  great  quantities  of  gas  and  fluid,  relieves 
the  distension,  and  probably,  by  its  physiological  action, 
relieves  engorgement  of  intestinal  vessels.  A  Seidlitz  powder 
or  a  dose  of  Epsom  salts  will  sometimes  act  like  a  charm  in 
these  cases,  putting  an  altogether  new  complexion  on  the  case. 
I  believe  also  that  a  saline  purge  may  be  of  advantage  where  there 
is  fluid  collecting  in  the  pelvis.  The  engorgement  of  its  vessels 
being  relieved,  the  peritoneum  is  able  to  absorb  more  fluid.  Tait 
tells  us  that  in  many  cases  where  others  would  drain,  he  purges. 

Over  and  over  again  I  have  been  able  to  demonstrate  to 
students  and  medical  men  the  value  of  a  saline  purge  in  cases  of 
incipient  peritonitis.     A  case  seen  with  distension,  sickness  and 


94  TREATMENT  AFTER   ABDOMINAL   OPERATIONS. 

restlessness  at  the  visit  on  one  da}^,  has  a  SeidHtz  powder  pre- 
scribed, to  be  followed  by  a  hot  water  or  turpentine  enema ;  and  it 
is  almost  taken  for  granted  that,  at  the  visit  next  da}^  the  patient 
will  have  a  flat  abdomen,  the  sickness  will  have  disappeared, 
and  she  will  express  herself  as  feeling  infinitely  better,  but  weak 
from  the  exertion  necessary  in  passing  motions.  A  brandy 
enema  at  once  counteracts  any  feeling  of  w^eakness.  Food  is 
now  jtolerated ;  and  the  patient  is  practically  out  of  danger.  In 
grave  abdominal  cases,  I  positively  like  to  see  diarrhoea — natural 
or  artificial :  diarrhoea  very  rarely  goes  with  vomiting.  It  is  one 
mode  of  draining  the  peritoneum,  as  well  as  being  an  antagonist 
to  tympanitic  distension.  It  may  be  that  purges  do  good  rather 
as  removing  gas  than  as  draining  the  peritoneum  and  relieving 
engorgement  of  vessels  :  how  they  do  good  matters  not  so  much 
as  the  fact  that  they  do. 

Slowly  but  surel}^  the  therapeutic  virtues  of  purges  in  opera- 
tion-peritonitis are  being  recognised.  Among  the  most  enthu- 
siastic supporters  of  the  plan  are  such  well-known  surgeons  as 
Gill  Wylie,"  Boldy,t  Penrose, |  and  Gardner. §  The  last  named, 
the  well-known  Professor  of  Gynaecology  in  McGill  University, 
in  recording  his  highly  successful  work  during  the  year  1886, 
thus  wTites  of  it:  "In  my  work  during  the  year  I  have  given 
no  opium,  and  invariably,  immediately  on  the  appearance  of 
distension,  pain,  or  vomiting,  I  have  given  enemas  and  purga- 
tives with  the  most  signal  advantage.  I  am  convinced  that,  in 
my  own  experience,  I  have  thus  seen  many  lives  saved,  besides 
a  vast  diminution  of  the  trouble  and  difficulty  in  managing  the 
cases  afterwards." 

Tympanites  is  a  symptom  which  always  accompanies  peri- 
tonitis and  vomiting.  In  a  slight  degree,  elevating  the  infra- 
sternal  depression,  it  may  mean  nothing  more  than  passive 
accumulation  of  gas  from  relief  of  intra-abdominal  pressure. 
Drum-like  distension  accompanying  peritonitis  is  quite  another 
affair;  it  may  cause  distress  from  interfering  with  respiration :  it 
is  certainly  a  cause  of  vomiting,  probably  through  its  acting  as 

*  N.  Y.  Med.  Rec.  Mar.  19th,  1887.  f  N.  Y.  Med.  Rec.  Nov.  5th,  1887. 

J  Phila.  Med,  and  Surg.  Rep.  Oct.  22nd,  1887. 

§  Canada  Med.  and  Surg.  Journ.,  p.  147.     Oct.,  1887. 


THE  RECTUM   TUBE.  95 

an  obstructive,  and  must  be  relieved  as  soon  as  possible.  Tap- 
ping with  a  fine  trocar  may  give  temporar}'  relief;  but  this  relief 
is  so  slight  and  so  evanescent  as  to  be  practical^  of  no  account. 
Speaking  from  a  personal  experience  of  six  cases,  and  from  the 
observation  of  several  more  in  the  practice  of  colleagues  and 
friends,  I  would  characterise  tapping  of  the  bowels  for  tympa- 
nites as  a  simple  trifling  with  the  complaint,  and  as  a  dangerous 
trifling.*  More  advantage  will  be  derived  from  encouraging 
free  vomiting  in  the  manner  indicated  above,  and  by  large  fluid 
rectal  injections,  supplemented,  where  it  is  considered  advisable, 
by  a  saline  purge.  Spirits  of  peppermint,  ether,  or  chloroform, 
facilitate  the  eructation  of  gas,  and  may  be  of  some  benefit. 

A  most  valuable  adjuvant  in  the  treatment  of  distension 
after  abdominal  operations  is  the  employment  of  the  rectum 
tube.  The  vaginal  tube  supplied  with  a  Higginson's  syringe, 
or  an  ordinary  lithotomy  tube,  answer  the  purpose  perfectly 
well.  But  sometimes  a  longer  tube,  such  as  that  used  for  w^ash- 
ing  out  the  stomach,  will  be  required.  If  there  is  fluid  in  the 
rectum,  such  as  remains  of  enemas  or  liquid  faces,  then  the 
long  tube  should  be  employed  to  carry  the  discharge  well  away 
from  the  patient's  body,  or  a  piece  of  rubber  tubing  should  be 
attached  to  the  ordinary  tube,  and  carried  outside  the  bed- 
clothes. As  soon  as  there  is  a  collection  of  gas  in  the  bowel 
which  the  patient  cannot  pass,  the  rectum  tube  should  be  in- 
serted and  left  in  position.  When  there  is  much  distension,  the 
tube  should  literally  be  worn  for  as  long  periods  as  possible 
consistently  with  the  administration  and  retention  of  enemas. 
The  patient  very  soon  appreciates  the  virtues  of  the  rectum 
tube,  and  frequently  will  ask  that  it  be  inserted. 

The    trinity  of  peritonitis,  tympanites,  and  vomiting  are  the 

furies  of  abdominal  surgery.     When  they  have  taken  firm  hold 

of  a  case,  we  may  make  up  our  minds  for  a  fierce  struggle  before 

they  can  be  ousted.     The  longer  they  abide,  the  more  difficult 

*  See,  on  this  subject,  Ogle,  Lancet,  July  i6th  and  23rd,  18S7.  In  cases 
of  tympany  occurring  in  cattle,  the  part  punctured  is  not  the  bowel,  as  Dr.  Ogle 
seems  to  suppose,  but  the  rumen  or  paunch.  Not  only  in  this  respect  but 
in  others,  such  as  the  thickness  of  the  visceral  walls,  and  the  nature  of  the 
contents,  the  analogy  between  human  beings  and  cattle  is  not  correct. 


96  TREATMENT  AFTER   ABDOMINAL   OPERATIONS. 

are  they  to  be  got  rid  of :  therefore,  we  ought  to  be  prepared  at 
every  point  to  meet  them  with  the  most  trustworthy  weapons 
and  the  most  approved  tactics. 

Rectal  Feeding. — The  frequent  necessity,  in  abdominal  cases, 
of  feeding  by  the  rectum  demands  a  practical  familiarity  with 
the  best  modes  of  preparing  the  food,  and  the  best  means  of 
adniinistering  it.  I  have  closely  followed  the  accounts  of  modern 
improvements  in  the  artificial  digestion  of  foods,  and  have 
specially  taken  note  of  the  results  found  from  introducing  these 
into  the  system  by  rectal  absorption.  Most  of  the  plans  recom- 
mended I  have  either  tried  or  seen  tried  in  practice.  Now,  it  is 
of  supreme  importance  that  feeding  by  rectum  shall  produce 
a  maximum  of  result  with  a  minimum  of  disturbance.  The 
worry  of  rectal  feeding  must  be  counterbalanced  by  very  definite 
and  palpable  results  ;  it  must  be  something  very  much  more 
than  an  interesting  physiological  experiment. 

I  have  come  to  the  conclusion  that  all  rectal  foods  ought  to 
possess  two  qualifications — namely,  that  they  should  be  pep- 
tonised,  and  that  they  should  be  very  dilute.  It  is  idle  to  argue 
that  enemas  are  not  nutritive  unless  they  are  peptonised  ;  long 
and  extensive  experience  has  abundantly  proved  the  contrary. 
But  it  seems  fairly  well  established  that  digested  food  is  more 
readily  absorbed  by  the  mucous  membrane  of  the  bowel  than 
undigested  food,  and  is  possessed  of  a  higher  nutritive  value. 
The  nutritive  value  of  dried  bullock's  blood,  or  any  of  the 
nutritive  boluses  or  capsules  which  are  now  prepared  by  various 
chemists,  is  no  doubt  considerable.  But,  for  the  treatment  of 
abdominal  cases  at  least,  I  believe  that  the  best  results  are  got 
from  enemas  that  are  dilute. 

It  is  just  possible  that  the  benefits  of  dilute  enemas  may,  to 
some  extent,  be  accounted  for  by  the  relief  to  thirst  which  they 
give.  Thirst  is  undoubtedly  a  frequent  complaint  in  abdominal 
cases ;  and  in  such  as  have  vomiting,  the  thirst  is  often  trying. 
No  doubt  the  fluids  of  the  blood  are  largely  drawn  upon  to 
provide  the  intestinal  fluids  which  are  secreted  so  abundantly; 
but  the  feeling  of  thirst  may  also  be  partly  accounted  for,  as 


PYREXIA .  97 

analogous  to  the  thirst  which  is  felt  after  shock  or  fainting. 
However  it  is  explained,  there  is  no  doubt  that  the  feeling  is 
removed  by  the  use  of  liquid  enemas,  when  drinking  of  fluids 
may  be  ineffectual.  On  the  other  hand,  as  regards  the  supply 
of  nourishment,  enemas  are  not,  in  operation  cases,  usually  ad- 
ministered because  the  patient  is  famished  for  want  of  food,  but 
because  we  wish  to  provide  temporary  support,  to  enable  the 
patient  to  tide  over  a  few  days  of  exhausting  sickness.  Only  in 
the  case  of  gastrostomy  for  stricture  of  the  oesophagus  have  we 
to  combat  real  hunger ;  in  other  operations,  it  is  temporary 
support  or  stimulation  which  we  seek  to  provide.  Prof.  Bauer* 
insists  upon  it  that  by  the  help  of  nutrient  enemas,  however 
prepared;  it  is  impossible  to  effect  the  absorption  of  more  than 
a  fourth  part  of  the  nourishment  necessary  for  subsistence. 
This  tells  in  favour  of  the  exhibition  of  stimulants  in  the 
enemas,  which  undoubtedly  are  absorbed. 

Now,  in  practice' these  principles  may  be  carried  out  in  two 
ways — either  by  the  administration  of  enemas  that  are  very 
dilute,  and  therefore  in  considerable  bulk,  or  by  the  administra- 
tion four  or  five  times  in  the  twenty-four  hours  of  small  con- 
centrated bulks  of  food,  with,  once  a  day,  the  ingestion  of  a 
considerable  quantity  of  tepid  water.  Some  patients  will,  with- 
out discomfort,  retain  a  pint  of  fluid  in  the  large  bowel ;  these 
I  should  feed  with  dilute  peptonised  enemas.  A  few  can  retain 
no  more  than  four  or  six  ounces  ;  these  I  should  feed  with  concen- 
trated or  solid  peptonised  materials,  supplemented  by  the  adminis- 
tration, once  or  twice  daily,  of  a  pint  or  more  of  warm  water. 

Pyrexia. — A  few  surgeons  consider  it  necessary  to  make 
special  provision  for  the  treatment  of  excessive  pyrexia  occur- 
ring after  abdominal  operations.  Nothing  perhaps  is  more 
remarkable  in  the  whole  range  of  practical  surgery  than  the 
slight  amount  of  febrile  reaction  which  is  observed  after 
abdominal  operations.  Case  after  case  occurs  in  which  the 
maximum  temperature  does  not  reach  ioo°  Fah. ;  in  fact,  a 
temperature  of  ioo°  may  be  considered  as  abnormally  high.  It 
is  also  true  that  the  greatest  dangers  after  laparatomy  are  not 
*  Von  Ziemmssen's  Handhooh  of  General  Therapeuties,  vol.  i.  p.  266. 

8 


98  TREATMENT  AFTER   ABDOMINAL   OPERATIONS. 

associated  with  severe  p3frexia.  Peritonitis  of  the  most  virulent 
sort  may  co-exist  with  a  normal  or  even  sub-normal  temperature; 
and  ordinary  peritonitis,  mild  or  local,  rarely  causes  great  eleva- 
tion of  temperature.  Pyrexia  after  laparotomy  is  not  of  the 
nature  of  the  pyrexia  in  specific  diseases  such  as  typhoid  fever: 
it  does  not  continue  for  weeks  together,  and  it  is  not  at  all  likely 
to  cause  danger  from  mere  continuance  of  excessive  fever  heat. 
It  is  probably  true  that  laparotomy  involves  a  likelihood  of  rapid 
and  dangerous  rise  in  temperature  no  more  than  any  other  major 
surgical  operation ;  and  this  likelihood  must  be  exceedingly 
small.  In  the  unrivalled  experiences  of  Tait  and  Keith,  such 
dangerous  rises  of  temperature  have  not  occurred ;  and  it  may 
reasonably  be  argued  that,  in  the  practice  of  others,  no  special 
preparations  need  be  made  to  meet  them. 

In  the  Samaritan  Hospital,  the  ice-cap  is  kept  in  reserve  and 
frequently  used  for  the  treatment  of  rises  in  temperature.  Cold 
packs  on  the  limbs  are  used  for  the  same  end.  And  in  America 
a  few  surgeons  speak  of  the  value  of  Kibbee's  fever  cot,  which 
is  essentiall}'^  a  water-bed,  through  which  cold  water  can  be 
passed,  so  as  to  abstract  heat  from  the  body  with  which  it  is  in 
contact.  If  I  had  to  deal  with  a  temperature  above  104°  lasting 
for  more  than  two  hours,  I  should  administer  a  full  dose  of 
antipyrin,  and  possibly  supplement  it  with  sponging  of  the 
cutaneous  surface.  Under  104°,  I  should  adopt  no  special 
treatment  to  reduce  the  temperature;  the  strong  probability 
is,  that  it  will  soon  drop  of  its  own  accord. 

Parotiiis. — Goodell,  Stephen  Paget,  and  others  have  called 
attention  to  the  fact,  that  after  abdominal  injuries  and  opera- 
tions a  small  proportion  of  cases  is  attacked  with  inflammation 
of  the  parotid  gland,  which  may  or  may  not  proceed  to  sup- 
puration. The  explanation  of  this  fact  has  been  supposed  to  be 
due  to  the  sympathy  between  the  parotid  gland  and  the  ovaries. 
But  the  disease  has  been  found  in  connection  with  abdominal 
operations  not  concerned  with  the  sexual  organs.  The  treat- 
ment is  carried  out  on  ordinary  surgical  principles. 

{See  Bibliography  at  end  of  Book.) 


Section  III. 


OPERATIONS  ON  THE  OVARIES,  THE  FALLOPIAN 
TUBES,  AND  THE  BROAD  LIGAMENTS. 


By  far  the  most  important  and  extensive  part  of  abdominal 
surgery  is  concerned  with  tumours  of  the  ovary.  It  was  here 
that  the  surgery  of  the  abdomen  signahsed  its  first  triumphs ; 
and  it  has  been  chiefly  through  the  practical  experience  gained 
in  this  field  that  the  present  proud  position  of  peritoneal  surgery 
has  been  established. 

In  this  section  we  have  to  deal  with  the  ovaries,  the  broad 
ligaments  and  parovarium,  and  the  Fallopian  tubes.  For  the 
sake  of  practical  convenience,  inflammatory  diseases  of  the 
ovaries  are  considered  along  with  diseases  of  the  Fallopian 
tubes ;  the  whole  being  collectively  treated  under  Removal  of 
the  Uterine  Appendages.  Operations  for  growths  in  the  broad 
ligament  and  parovarium,  though  they  are  usually  described  as 
ovariotomies,  are  here  separately  considered. 

8  * 


Ovariotomy. 

SURGICAL  ANATOMY  OF  THE  OVARY. 

The  ovaries  lie  in  the  posterior  fold  of  the  broad  ligament, 
at  the  level  of  the  brim  of  the  pelvis.  In  front,  they  are  in 
contact  with  the  broad  ligaments ;  behind,  they  are  separated 
from  the  rectum  by  the  coils  of  ileum  which  usuall}^  occup}^ 
Douglas's  pouch.  Their  position  is  not  fixed  and  stable  ;  dis- 
placements are  caused,  normally,  by  the  filling  and  emptying 
of  the  bladder  and  the  rectum  ;  and,  pathologically,  by  enlarge- 
ments and  malpositions  of  the  uterus. 

The  ovary  is  attached  to  the  broad  ligament  along  one 
border,  and  to  the  uterus  by  a  rounded  fold  of  peritoneum 
containing  muscular  fibre  (the  utero-ovarian  ligament),  which 
is  inserted  into  its  internal  extremity ;  at  its  external  extremity 
is  attached  that  part  of  the  upper  border  of  the  broad  ligament 
known  as  tubo-ovarian  or  infundibulo-pelvic.  The  ovary  there- 
fore occupies  the  apex  of  a  ligamentous  triangle,  the  base  of 
which  is  in  the  broad  ligament,  and  the  angles  of  which  lie  at 
the  uterus  and  the  pelvic  brim. 

At  the  junction  of  the  ovary  with  its  fold  of  broad  ligament 
is  the  hilum  of  the  ovary.  Here  is  situated  the  mass  of  spongy 
vascular  erectile  tissue  known  as  the  bulb  of  the  ovary,  and  to 
this  point  converge  the  numerous  small  vessels,  branches  of  the 
ovarian  artery,  which  supply  the  gland.  The  ovarian  arter}^  a 
branch  of  the  aorta,  leaving  the  inner  aspect  of  the  iliac  vessels 
at  the  pelvic  brim,  runs  a  tortuous  course  along  the  upper  border 
of  the  broad  ligament,  between  its  folds,  to  its  bifurcation  near 
the  uterus.  On  the  outer  side  of  the  ovary,  it  gives  off  branches 
to  the  ampulla;  and  on  the  inner  side,  to  the  isthmus  of  the 
Fallopian  tube  and  to  the  round  ligament ;  midway,  it  gives  off 
the  branches  which  supply  the  ovary.  As  many  as  ten  or 
twenty  branches  may  be  given  off.  The  veins  are  even  more 
numerous,  and  constitute  a  closely-set  network,  which  com- 
municates above  with  the  pampiniform  plexus,  and  below  with 


SURGICAL   ANATOMY  OF  THE   OVARY.  101 

the  vaginal  plexus,  and  is  finally  gathered  into  the  ovarian  vein, 
which  discharges  itself  into  the  renal  vein  on  the  left  side,  and 
into  the  vena  cava  on  the  right  side. 

The  fold  of  broad  ligament  containing  these  numerous 
arterial  and  venous  branches  constitutes  the  surgical  pedicle. 
A  ligature  placed  close  to  the  ovary  necessarily  constricts  all 
these,  but  may  not  include  the  trunk  of  the  ovarian  artery. 
Under  -ordinary  circumstances,  however,  constriction  of  these 
branches  by  ligature  interferes  with  the  circulation  of  the 
ovarian  artery,  and  may  even  check  it :  if  the  Fallopian  tube 
is  included  as  well,  the  chances  of  complete  occlusion  of  the 
ovarian  artery  are  increased. 

The  relations  of  the  ovary  to  the  Fallopian  tube  are  of 
importance.  The  observations  of  His,  confirmed  by  Doran, 
Tait,  Hart,  and  others,  seem  to  show  that  the  generally 
accepted  views  as  to  the  mutual  position  of  these  organs  are 
erroneous.  The  ovary  hangs  obliquely  from  its  ligament,  and 
the  Fallopian  tube  forms  a  loop  round  it,  running  from  without 
inwards  and  downwards.  The  fimbriae  of  the  tube,  thus  lie 
behind  and  below  the  ovary,  covering  a  considerable  portion 
of  its  surface.  It  would  further  appear  that  the  long  axes  of 
the  ovaries  do  not  lie  transversely,  but  in  lines  extending  for- 
wards and  outwards.  Considerable  variations  in  position  are, 
however,  compatible  with  normal  conditions. 

In  tumours  of  the  ovary  which  rise  into  the  abdomen,  the 
ovarian  attachments  are  stretched  and  drawn  out,  forming  the 
so-called  "  pedicle."  Such  a  pedicle  contains,  not  only  the  true 
ligaments  of  the  ovary,  but  also  part  of  the  broad  ligament,  and 
in  the  great  majority  of  instances  the  Fallopian  tube  as  well. 
The  surgical  management  of  this  pedicle,  not  yet  finally  settled, 
has  been  one  of  the  most  fertile  sources  of  dispute  in  abdominal 
surgery. 

The  weight  of  the  healthy  ovary,  according  to  Farre,  varies 
from  60  to  135  grains.  Its  average  diameters  are:  longitudinal, 
I J  in.;  transverse,!-  in.;  perpendicular,  |  in.;  but  these  are 
liable  to  considerable  variations. 

It  is  necessary  to  emphasise  the  fact,  that  in  women  who 


102  OVARIOTOMY. 

have  borne  children,  as  well  as  in  many  who  have  not,  the 
normal  topography  of  the  ovary  may  be  much  disturbed  with- 
out causing  symptoms.  I  have,  on  many  occasions,  noted  the 
position  of  the  ovaries  in  cases  which  have  appeared  on  the 
post-mortem  table  of  the  Bristol  Infirmary,  and  I  have  been 
much  impressed  with  the  variety  of  position  which  the  ovaries 
have  assumed  without  causing  symptoms  which  were  noted 
during  life.  The  most  common  displacement  is  downwards, 
chiefly  from  elongation  of  the  infundibulo-pelvic  ligament, 
permitting  the  outer  extremity  to  drop  lowest,  and  the  whole 
to  gravitate  towards  Douglas's  pouch.  On  the  left  side,  dis- 
placements are  perhaps  most  common.  I  have  found  health}^ 
non-adherent  ovaries  on  the  brim  of  the  true  pelvis  at  the 
insertion  of  the  broad  ligament,  at  the  sacro-iliac  articulation, 
in  front  of  the  broad  ligament,  behind  the  internal  inguinal  ring, 
and  in  an  almost  endless  variety  of  abnormal  situations. 

This  distensibility  of  the  ovarian  ligaments  has  advantages 
from  the  surgical  point  of  view.  It  permits  of  the  glands  being 
brought  to  the  surface  in  abdominal  sections ;  or  into  the  vagina, 
where  removal  by  this  method  is  contemplated. 

MULTILOCULAR    AND    GLANDULAR    CYSTS    OF    THE    OVARY.       OVARIAN 

CYSTOMA. 

Pathological  Anatomy, — The  investigations  of  our  most  com- 
petent pathologists  would  seem  to  favour  the  view  that  true 
cystic  disease  has  its  origin  in  connection  with  the  natural 
retrograde  metamorphosis  of  the  Graafian  follicle.*  The  steps 
which  lie  between  the  first  changes  in  the  ovary  and  the 
fully  developed  cystoma  have  not  been  clearly  traced.  The 
pathological  appearances  vary  much  in  detail,  but  they  are 
sufficiently  definite  in  general  to  make  the  recognition  of  an 
ordinary  cystoma  a  matter  of  no  difficulty. 

An  ovarian  cystoma  usually  consists  of  one  large  cyst  and  a 
varying  number  of  small  ones.     As  a  rule,  the  large  cyst  lies 

*  This  and  other  questions  in  ovarian  pathology  are  philosophically 
handled  by  Alban  Doran,  in  his  work  on  Tumouys  of  the  Ovary,  Fallopian  Tube, 
and  Broad  Ligament.     London,  1884. 


OVARIAN  CYSTOMA.  103 

farthest  away  from  the  peduncular  attachment  of  the  tumour, 
the  smaller  cysts  being  placed  near  to  this  site  of  attachment ; 
but  there  are  many  exceptions  to  this  rule.  The  walls  of  the 
cyst  are  composed  of  pure  fibrous  tissues  of  varying  thickness. 
They  are  covered,  on  the  outside,  with  flattened  cubical  cells, 
closel}^  resembling  ordinary  endothelium  ;  on  the  inside,  with 
endothelium  and  varieties  of  glandular  cells.  The  fluid  in 
ovarian  cysts  is  typically  of  a  glairy  or  colloid  nature ;  white, 
■or  grey,  or  greyish-yellow,  in  colour ;  very  albumious,  and  of 
high  specific  gravity. 

When  exposed  to  view,  an  uninflamed  multilocular  cyst 
presents  a  white  glistening  or  pearly  surface,  perfectly  smooth 
to  the  touch.  If  secondary  cysts  be  in  the  cyst-wall,  they  may 
protrude  outwards,  forming  smooth  rounded  bosses  of  varying 
size  on  the  main  cyst ;  or  they  may  bulge  inwards,  showing 
areas  of  different  colour  and  consistency  on  the  surface  of  the 
cyst -wall.  The  fluid  found  in  the  chief  cyst  is  usually  of  the 
glairy  nature  already  described ;  but  sometimes  it  is  watery  and 
colourless,  when  we  are  told  to  expect  papillomatous  growths 
inside  ;  and  not  unfrequently  it  is  dark  red,  brown,  or  chocolate 
coloured,  from  admixture  with  blood.  When  masses  of  glandular 
semi-solid  material  are  developed  in  the  centre  of  the  cj^st,  the 
fluid  is  said  to  become  thick  and  colloid,  almost  coherent.  In 
the  secondary  cysts  the  nature  of  the  fluid  is  still  more  variable. 
Some  of  these  have  pale  watery  contents  ;  others,  almost  pure 
blood  ;  others,  very  thick  stringy  or  colloid  material ;  and  some 
may  contain  fluid  indistinguishable  from  pus.  In  closely-set 
small  cysts  the  contents  are  most  frequently  colloid  or  jelly-like, 
capable  of  being  lifted  out  by  the  fingers,  and  too  thick  to  be 
drawn  off  by  cannula. 

Much  has  been  written  on  the  possibility  of  diagnosing 
ovarian  fluid  through  its  chemical  composition  and  microscopic 
constituents  :  even  the  spectroscope  has  been  called  in  to  aid 
us.  Chemistry  has  certainly  failed,  and  so  has  the  spectroscope; 
and  the  presence  of  certain  peculiar  cells,  which  were  for  some 
time  considered  as  pathognomonic,  has  now  been  proved  almost 
valueless   for   diagnostic    purposes.     The    vacuolated    cells   of 


104  OVARIOTOMY. 

Thornton  and  Foulis  are  now  known  not  to  be  characteristic  of 
maHgnant  disease,  as  was  at  one  time  thought  certain  ;  and  we 
are  now  practically  left  without  any  single  reliable  physical 
test  of  the  contents  of  an  ovarian  cyst.  We  can  say  that  a 
fluid  is  ovarian  with  a  greater  probability  of  truth  than  we  can 
say  that  it  is  not ;  and  in  most  cases  the  grounds  of  this  state- 
ment might  rest  as  securely  on  the  simple  visual  appearance 
of  the  fluid,  as  on  its  composition  or  the  nature  of  the  cells 
contained  in  it.  But  the  value  of  all  such  tests  is  best 
estimated  by  the  weight  which  practical  men  put  upon  it — 
and  that  is  almost  nil.  We  never  hear  of  the  removal  of 
ovarian  fluid  for  examination ;  the  diagnosis  is  made  by  other 
means. 

Certain  developmental  changes  are  found  in  cystomata. 
Thus,  from  crowding  of  secondary  cysts,  their  continguous  walls 
may  disappear,  and  the  cavities  may  communicate.  Or  the 
wall  of  the  main  cyst  may  be  ruptured,  and  the  secondary  cysts, 
protruding  through  the  opening,  may  form  the  chief  bulk  of  the 
tumour.  In  such  cases  the  operation  for  removal  is  usually 
difficult,  on  account  of  the  tenuity  of  the  cyst-walls,  the  density 
of  their  contents,  and  their  tendency  to  become  adherent  to 
abdominal  organs.  A  curious  variety  is  the  so-called  tubo- 
ovarian  cyst,  where  there  is  a  free  communication  between  the 
cyst-cavity  and  the  distended  Fallopian  tube  adherent  by  its 
fimbriated  extremity.'''  From  the  fact  that  the  cyst  in  the 
ovary  is  usually  monolocular  and  thin-walled,  and  rarely  is  found 
large,  it  is  probable  that  the  original  growth  in  these  cases  is  not 
a  true  glandular  cystoma,  but  a  simple  cyst  such  as  is  found  in 
chronic  inflammation.  A  rare  and  somewhat  puzzling  condition 
arises  when  there  are  two  ovarian  cysts,  and  their  walls  become 
fused,  while  their  cavities  communicate.  In  this  case  there  are 
two  pedicles  to  deal  with.  Solid  matter  inside  a  cystoma, 
Doranf  found  present  in  26  out  of  366  cases,  and  in  14  of 
these  the  structure  was  adeno-sarcoma.  In  nearly  a  third  of 
his  cases  glandular  material   was  present  in  varying  amount. 

*  See  Griffith,  Obstct.  Trans.,  xxix.,  1887. 
t  0/.  Cif.,  p.  21. 


DIAGNOSIS   OF  CYSTOMA.  105 

Thin-walled  pedunculated  and  sessile  cysts  are  sometimes  found 
attached  to  the  main  wall.  Other  peculiar  developments — as, 
small  localised  masses  of  connective  tissue,  or  wart-like  bodies, 
or  even  true  papilloma — may  be  found  growing  on  the  inner 
surface  of  the  cyst.  Certain  changes  or  accidents  liable  to 
take  place  in  the  developed  growth  will  be  referred  to 
further  on. 

All  such  growths  have  a  pedicle :  a  so-called  sessile  ovarian 
cystoma  is  simply  one  with  a  very  short  pedicle.  This  pedicle 
is  a  very  variable  structure.  In  length,  it  varies  from  six  inches 
or  even  more,  down  to  a  vanishing  point ;  in  breadth,  it  varies 
between  that  of  the  whole  length  of  the  broad  ligament  and 
some  fraction  of  an  inch ;  and  in  thickness,  its  dimensions  lie 
between  the  tenuity  of  membrane  and  the  bulk  of  the  palm  of 
the  hand,  or  even  more.  The  vessels  that  supply  the  growth, 
also  most  variable  in  size  and  number,  lie  in  the  pedicle. 
Anatomically,  a  true  pedicle  is  composed  of  the  ovarian 
ligaments,  some  portion  of  the  broad  ligament,  and  the 
Fallopian  tube — all  of  them  hypertrophied. 

Diagnosis. — There  is  something  characteristic  in  the  appear- 
ance of  an  abdomen  enlarged  by  an  ovarian  tumour.  There  is 
a  bulging  forwards,  not  so  marked  as  in  pregnane}^,  where  the 
tumour  appears  to  start  straight  out  of  the  pelvis  ;  and  more 
marked  than  in  ascites,  where  the  enlargement  involves  the 
whole  abdomen  and  causes  bulging  in  the  flanks.  The  position 
of  an  ovarian  tumour  of  moderate  size  is  best  suggested  by 
supposing  that  it  rests  chiefly  upon  the  promontor}/'  of  the 
sacrum.  It  occupies  the  lower  portions  of  the  abdominal 
cavity,  and  causes  stretching  of  the  parietes,  chiefly  in  these 
portions.  This  is  apparent  by  the  increase  of  distance  between 
the  umbilicus  and  pubes,  greater  than  between  the  sternum  and 
umbilicus,  and  by  the  appearance  of  lineae  albicantes  (where 
they  exist  at  all)  at  each  side  of  and  below  the  umbihcus. 

Palpation  reveals  a  rounded,  cystic  and  probably  fluctuating 
growth,  movable  in  most  cases,  and  remotely  connected  with 
the  uterus.     Small  tumours  appear  to  be  perfectl}'  globular,  and 


106  OVARIOTOMY. 

are  "Smooth  on  the  surface;  large  growths  are  usually  somewhat 
irregular  in  shape,  from  the  development  of  secondary  cysts  in 
their  walls.  In  thin-walled  cysts  which  are  not  greatly  sub- 
divided by  septa,  or  in  which  one  cj'st  considerably  exceeds  the 
others  in  size,  a  fluctuation  thrill  may  be  distinctly  felt.  If  the 
cyst-wall  is  thick,  or  if  the  growth  is  very  mutilocular,  or  its 
contents  colloid,  fluctuation  may  be  absent. 

■A  sensation  of  crepitus  may  be  produced  by  the  friction  of 
inflamed  surfaces ;  such  crepitus,  of  course,  centra-indicates 
adhesions  at  the  spot  where  it  is  felt.  The  diagnosis  of 
adhesions  is  very  imcertain ;  free  mobility  of  parietes  over 
tumour  indicates  that  there  are  not  closely  set,  dense,  or  short 
adhesions ;  long  bands  may  permit  considerable  mobility.  A 
condition  of  fixity  between  cyst-wall  and  parietes,  it  is  very 
difficult  to  be  assured  of.  Doran  mentions  a  case  in  which  he 
and  several  of  his  colleagues  thought  that  a  cyst  was  fixed 
to  the  abdominal  walls ;  but  not  a  single  parietal  adhesion 
was  found  when  the  operation  was  performed.  I  have  met 
with  several  analogous  instances ;  and  I  am  convinced  that 
the  diagnosis  of  parietal  adhesions  is  most  difficult  and  un- 
certain. 

Vaginal  palpation  reveals  a  uterus  normal  in  size,  displaced 
either  backwards  or  forwards,  or  to  one  side,  and  most  frequently 
depressed.  The  uterus  is  somewhat  frequently  enlarged — 
always  so,  if  the  growth  is  closely  adherent  to  it.  If  the  tumour 
is  small  and  has  not  escaped  from  the  pelvis,  the  uterus  will  be 
displaced  forwards  ;  when  the  growth  is  of  considerable  bulk 
and  placed  in  the  abdomen,  the  uterus  lies  indifferently  in  front 
of  or  behind  the  growth.  When  it  lies  in  front,  it  is  sometimes 
quite  easy  to  palpate  its  outlines  through  the  abdominal  wall 
above  the  pubes.  Rotation  of  the  growth  on  its  transverse  axis, 
by  no  means  a  rare  occurrence,  causes  the  uterus  to  be  dragged 
upwards.  If  the  growth  is  movable  and  the  pedicle  not  very 
long,  movements  communicated  to  it  are  felt  in  the  uterus.  If 
the  growth  is  large  or  fixed,  and  the  pedicle  short,  or  the  uterus 
adherent  to  it,  passage  of  the  sound  will  show  that  the  fundus 
of  the  uterus  cannot  be  moved  away  from  the  tumour.     This 


DIAGNOSIS   OF  CYSTOMA.  107 

sign  introduces  an  element  of  confusion  between  ovarian  and 
uterine  growths. 

By  percussion  we  diagnose  the  presence  of  a  non-resonant 
body  in  the  lower,  or  lower  and  middle,  abdomen.  From  the 
point  where  the  growth  comes  into  contact  with  the  parietes 
above,  down  to  the  pubes,  dulness  is  absolute.  Over  the 
anterior  aspect  of  the  tumour  there  is  also  absolute  dulness  ;  at 
the  sides  this  dulness  is  not  so  absolute,  and  in  the  flanks  there 
is  positive  resonance.  Tait  well  describes  the  ovarian  tumour 
as  being  surrounded  with  a  "  tympanic  corona,"  a  ring  of 
resonance  marking  the  lateral  and  upper  limits  of  growth, 
where  the  bowel  crowds  round  it  and  comes  into  contact  with 
the  parietes.  If  the  tumour  is  large,  there  may  be  dulness  in 
one  or  even  both  flanks ;  sometimes,  in  very  large  growths, 
resonance  is  absent  over  the  whole  abdominal  area.  Ascites 
associated  with  the  tumour  may  cause  lumbar  dulness,  as  may 
loaded  bowels. 

Auscultation  reveals  little  of  positive  value  in  the  diagnosis 
of  ovarian  cysts.  Negatively  it  may  be  useful,  as  showing  the 
absence  of  sounds  characteristic  of  other  conditions.  Ex- 
ploratory puncture  has  practically  been  abolished  as  a  means  of 
diagnosing  ovarian  cysts. 

As  regards  general  and  subjective  symptoms,  experience 
shows  that  they  are  almost  valueless.  Some  tumours  grow 
quickly,  some  slowly ;  some  are  very  painful ;  others  attain  to 
enormous  dimensions,  producing  nothing  more  than  discomfort 
from  their  bulk.  Menorrhagia,  amenorrhoea,  or  normal  uterine 
functions,  are  found  present  with  equal  impartiality.  Dis- 
turbances of  micturition  or  of  defaecation  may  exist,  or  they 
may  not.  Sickness  is  not  a  very  common  symptom,  but  there 
are  cases  where  sickness  and  vomiting  are  very  troublesome. 
CEdema  of  legs,  parietes,  or  vulva,  may  be  found  in  small 
growths,  and  they  may  be  absent  in  very  large  ones.  Disturb- 
ances of  the  renal  functions  are  present  or  absent.  And  so  it  is 
through  the  whole  group  of  rational  and  associated  symptoms  ; 
there  is  not  one  whose  absence  disproves  ovarian  disease,  and 
not  one  whose  presence  proves  it ;  indeed,  there  is  perhaps  no 


108  OVARIOTOMY. 

association  of  such  symptons  which  would  be  of  the  slightest 
value  for  accurate  diagnosis.  This  must  rest  on  the  physical 
bases  alone. 

The  diagnosis  of  ovarian  from  other  abdominal  tumours  is  a 
very  large  subject  indeed.  It  is  literally  the  fact  that  there  is 
scarcely  a  single  form  of  abdominal  growth,  of  dimensions  as 
large  as  a  child's  head,  that  has  not  been  mistaken  for  ovarian 
tumoiir.  No  doubt  some  of  these  mistakes  are  to  be  accounted 
for  by  carelessness  or  ignorance ;  but  many  of  them  have 
occurred  in  the  hands  of  our  most  distinguished  operators. 
But  such  mistakes  are  daily  becoming  less  common  ;  advancing 
knowledge  of  all  tumours  is  narrowing  down  the  diagnosis  of 
each.  The  earlier  writers  put  before  us  a  list  of  growths  which 
might  be  mistaken  for  ovarian  that  was  almost  co-extensive 
with  abdominal  tumours ;  at  present,  we  should  be  perhaps 
right  in  limiting  our  differentiation  to  half-a-dozen.  Ovarian 
C3'stic  disease  is,  I  think,  most  liable  to  be  confounded  with  the 
following : 

Encysted  Peritoneal  Dropsy. 

Renal  Cystic  Tumours. 

Cysts  of  the  Broad  Ligament. 

Fibro-cystic  Disease  of  the  Uterus. 

Ascites. 

In  many  cases  encysted  dropsy  of  the  peritoneum  cannot  be 
diagnosed  from  ovarian  C3^st.  The  points  specially  to  be  looked 
into  are  :  whether  or  not  there  is  resonance  between  the  pubes 
and  the  tumour — a  condition  sometimes  found  in  enc3'sted 
dropsy,  but  never  in  ovarian  cyst ;  whether,  on  deep  pressure 
at  the  periphery  of  tlie  cyst,  the  bowels  appear  to  be  sessile  on 
its  walls — or  rather,  whether  the  growth  appears  to  spring  from 
the  midst  of  the  coils  of  intestine.  It  is  rarely  the  case  that 
an  ovarian  cyst  small  enough  to  be  examined  in  this  way  is 
palpably  connected  closely  with  bowel.  The  walls  of  an 
encysted  peritoneal  collection  of  fluid  are  thin ;  and  there 
is    no   evidence   of  secondary  cysts,    and   herein   it   resembles 


FIBRO-CYSTIC   DISEASE.  109 

parovarian  cyst.  But  the  latter  is  very  rarely  adherent  to 
bowel,  and  still  more  rarely  appears  to  be  imbedded  in  intestinal 
coils.  The  fluid  is  under  low  pressure,  and  fluctuates  freely,  in 
encysted  dropsy. 

In  the  case  of  cystic  renal  tumours,  mistakes  are  not  likely  to 
arise  unless  the  growth  is  of  a  large  size,  filling  the  whole  of 
the  cavity,  and  unless  there  is  absence  of  special  urinary 
symptoms.  The  most  important  differentiating  sign  is,  in  the 
case  of  renal  growths,  deep  and  firm  fixation  in  one  or  other 
loin.  It  is  not  often  that  an  ovarian  cyst,  even  of  ver}^  large 
growth,  so  completely  occupies  a  lumbar  hollow  as  a  renal 
growth.  An  ovarian  growth  may  completely  fill  the  costo-iliac 
space,  and  may  cause  the  flanks  to  bulge  ;  but  it  does  not 
app£ar  to  spring  from  this  region,  having  most  of  its  bulk  in 
and  around  it.  Not  much  value  can  be  attached  to  the  absence 
of  signs  derived  from  vaginal  palpation.  A  sign  of  importance 
is  the  palpation  of  large  bowel  on  the  surface  of  a  renal  tumour. 

Cysts  of  the  hroad  ligament  may  be  simple  monolocular  growths 
containing  fluid,  which  are  best  known  as  parovarian. cysts ;  or 
polycystic  growths,  arising  in  the  hilum  of  the  ovary,  or  else- 
where in  the  broad  ligament,  which  most  frequently  contain 
papillomatous  material.  A  simple  parovarian  cyst  is  thin- 
walled,  fluctuates  freely,  and  is  globular  and  smooth  on  the 
surface.  A  papillomatous  cyst  of  the  broad  ligament  is  multi- 
locular,  deeply  sessile  in  the  pelvis,  and  is  often  intimately 
connected  with  the  uterus,  which  is  usually  dragged  upwards. 
If  the  papillomatous  material  is  abundant,  there  is  bogginess 
rather  than  fluctuation. 

Fihro-cystic  disease  of  the  uterus  is  more  rare  than  is  commonly 
supposed.  It  is  probable  that  most  of  the  cases  described  as 
fibro-cyst  of  the  uterus  would,  in  the  light  of  our  more  perfect 
recent  pathological  knowledge,  have  been  recognised  as  ovarian 
or  broad  ligament  growths  which  had  become  intimately  adherent 
to  the  uterus.  Beyond  an  intimate  connection  with  the  uterus, 
which  may  exist  in  other  growths,  there  is  little  to  guide  us  in 
diagnosing  fibro-cyst.  The  striking  cases  described  by  Spencer 
Wells  presented  symptoms  which  were  not  very  characteristic. 


110  OVARIOTOMY. 

Ascites  is  perhaps  least  liable  of  the  conditions  mentioned 
to  be  mistaken  for  ovarian  cystoma.  Error  can  scarcely  arise 
unless  the  abdominal  distension  is  very  considerable.  In  dis- 
tinguishing minor  degrees  of  enlargement,  the  most  important 
guides  are  the  sites  of  the  areas  of  resonance  and  dulness.  An 
ovarian  cystoma  grows  upwards  from  the  pubes,  and  gives  a 
circular  area  of  dulness  in  the  middle,  surrounded  by  a  ring  of 
resonance  which  extends  backwards  into  the  flanks.  (Fig.  3.) 
Ascites  increases  from  the  flanks  forwards  (speaking  of  the 
supine  posture),  and  when  the  fluid  comes  into  contact  with  the 
anterior  parietes,  gives  a  crescentic  area  of  dulness,  the  con- 
cavity of  which  looks  upwards,  with  resonance  only  between 
the  sternum  and  this  crescentic  hollow.  (Fig.  2.)  In  ascites, 
when  the  enlargement  is  very  great,  there  may  be  dulness  up  to 
the  sternum  ;  and  when  ascites  is  present  with  ovarian  tumour, 
there  may  be  dulness  in  both  flanks.  Under  these  conditions 
diagnosis  may  be  somewhat  difficult.  Variations  of  posture 
increase  the  resonant  areas  in  ascites  more  than  in  cystoma, 
and  the  fluctuation  thrill  is  more  distinct  in  ascites.  Also,  in 
ascites,  there  is  more  bulging  or  bagging  of  the  distensile 
portions  of  the  abdominal  sac  at  the  loins,  in  Douglas's  pouch, 
and  at  the  umbilicus ;  and  the  whole  belly  is  flatter  than  in 
cystoma. 

DERMOID    CYSTS    OF    THE    OVARY. 

About  one  of  ten  ovarian  tumours  is  either  entirely  or 
partially  dermoid.  Their  exact  origin  is  still  matter  of  un- 
certainty, and  need  not  here  be  discussed.  It  is  generally 
agreed  that  the  rudiments  of  all  dermoid  cysts  exist  at  birth, 
and  that  they  may  remain  quiescent  indefinitely,  or  start  into 
active  growth  at  any  period  from,  or  even  before,  birth  to  old 
age.  Dermoid  ovarian  growths  most  frequently  manifest  them- 
selves after  puberty. 

Dermoid  cysts  are  rarely  of  large  size ;  it  is  not  often  that 
they  are  larger  than  a  child's  head.  The  bulk  of  their  contents 
is  composed  of  a  thick  greasy  material,  such  as  is  found  in 
sebaceous   tumours   of    the   scalp.      The   cyst-wall    inside   the 


DERMOID  CYSTS.  Ill 

fibrous  envelope  is  composed  of  structures  similar  to  those  found 
in  the  skin.  From  within  outwards,  we  meet,  first,  with  a  layer 
of  epidermis,  from  which  sprouts  a  growth  of  hair,  and  in  which 
we  may  often  detect  rudiments  of  all  the  elements  found  in 
healthy  skin  ;  outside  of  this  lies  a  la3'er  of  connective  tissue, 
corresponding  to  the  cutis ;  and  outermost  of  all,  under  the 
fibrous  capsule,  is  a  layer  of  fatty  tissue,  corresponding  to  the 
panniculus  adiposus. 

A  dermoid  ovarian  cyst  is  usually  divided  by  septa  into 
separate  portions ;  and  the  contents  may  differ  in  the  various 
loculi.  The  main  cyst  often  contains  a  greasy  chocolate- 
coloured  fluid,  while  the  others  are  full  of  the  characteristic 
sebaceous  material.  Hairs  may  be  shed  into  the  cavities  in  large 
quantities,  and  sometimes  form  masses  which  appear  as  if  they 
had  been  rolled  into  balls.  But  the  most  striking  contents  are 
pieces  of  true  bone,  most  frequently  stunted  alveolar  pro- 
cesses, with  teeth  either  free  or  embedded  in  the  alveoli.  As 
many  as  three  hundred  teeth  have  been  found  in  one  dermoid 
cyst. 

There  usually  exists  a  very  perceptible  enlargement  of  the 
sebaceous  follicles  in  the  cyst-wall.  Frequently  they  attain  to 
the  dimensions  of  secondary  cysts,  and  a  similar  development 
may  take  place  in  the  sweat  glands.  Hyaline  cartilage  is  often 
found  in  the  cyst-wall ;  and  nerve-tissue,  unstriped  muscular 
fibre,  and  other  elements  may  be  detected.  Malignant  tumours 
have  been  found  growing  in  dermoid  cysts.  Last  year  in  the 
Bristol  Infirmar}'  I  removed  from  a  woman  aged  59  a  suppu- 
rating dermoid  cyst,  in  the  wall  of  which  was  a  solid  sarcomatous 
growth  as  large  as  an  hen's  egg.  As  yet  there  has  been  no 
secondary  development.  More  than  one  observer  has  noted 
that  malignant  tumours  of  the  abdominal  cavity  sometimes 
follow  removal  of  dermoid  cysts  :  no  doubt  the  primary  elements 
existed  in  the  dermoid  growths. 

Both  ovaries  are  liable  to  be  diseased  in  a  proportion  of 
cases  larger  than  in  cystoma.  Also,  ordinary  glandular  cystic 
disease  is  found  to  co-exist  with  dermoid  cyst  in  a  proportion  of 
instances  larger  than  would  be  likely  if  it  were  mere  coincidence. 


112  OVARIOTOMY. 

Any  casual  connection  between  the  two  is  not  likely  to  be  more 
than  a  stimulus  to  development  started  by  increased  vascular 
supply  from  the  one  which  first  began  to  take  on  diseased 
action. 

The  outer  aspect  of  a  dermoid  cyst  is  different  from  that  of 
an  ordinary  cystoma.  The  glisteniug  pearly  aspect  of  the  latter 
is  replaced  by  a  muddy  or  opaque  appearance  darker  in  colour, 
sometimes  even  approaching  to  brown.  Adhesions  are  common 
in  dermoid  cysts,  chiefly  because  they  are  liable  to  become 
inflamed. 

Diagnosis. — A  dermoid  cyst  may  be  suspected  ;  but  it  can 
rarely  be  accurately  diagnosed.  The  history' and  physical  signs 
of  dermoid  growth  may  be  identical  with  those  of  cystoma 
containing  colloid  material.  In  the  very  rare  event  of  bone 
being  discovered  by  bimanual  palpation,  diagnosis  is  certain ; 
and  this  is  perhaps  the  only  sign,  short  of  operation  or  explora- 
tory puncture  or  discharge  of  contents  by  suppuration,  which 
can  be  looked  upon  as  definitely  diagnostic.  A  thick  cyst-wall, 
bogginess  and  not  fluctuation,  and  a  size  less  than  that  of  a 
man's  head,  nearly  always  found  in  dermoid  cysts,  are  not 
infrequently  found  in  other  cystic  growths  of  the  ovaries. 


ACCIDENTAL    CHANGES    IN    CYSTIC    GROWTHS    OF    THE    OVARIES. 

Cystic  ovarian  growths  are  liable  to  certain  accidents  which 
are  not  necessarily  connected  with  their  pathological  develop- 
ment. The  most  important  of  these  are.  Rupture  of  the  Cyst- 
wall,  Twisting  of  the  Pedicle,  and  Inflammation  or  Suppuration 
in  the  growth. 

Rupture. — Any  breach  in  the  continuity  of  the  cyst-wall  may 
be  defined  as  a  rupture.  It  may  exist  either  as  a  slow  leakage 
through  a  minute  opening  or  openings,  or  as  a  rapid  evacuation 
of  contents  through  a  large  rent.  The  general  effects  of  rupture 
will  depend  on  the  size  of  the  cyst,  the  nature  of  its  contents, 
and  the  rapidity  with  which  they  are  discharged  into  the  peri- 
toneal cavity.     Simple  oozing  or  leakage  may,  if  the  contents 


TWISTING   OF  THE  PEDICLE.  113 

are  benign,  produce  no  symptoms  be3'ond  diminution  in  the  size 
of  the  cyst.  A  large  rent  may  result  in  collapse  or  rapid  death, 
or  may  slowly  pass  off,  or  may  terminate  in  peritonitis.  If  the 
contents  are  suppurating,  death  usually  results  from  peritonitis, 
unless  operation  is  performed ;  if  they  are  benign  and  watery, 
recovery  may  take  place  without  much  difficulty. 

The  causes  of  rupture  are  varied.  A  frequent  cause  is  over- 
growth of  intra-cystic  solid  matter,  usually  papillomatous ;  and 
in  this  case  the  rupture  is  of  the  nature  of  a  slow  leakage 
through  thinned  and  necrosed  portions  of  the  C3^st-wall,  and 
does  not  produce  very  acute  symptoms.  Spontaneous  rents 
may  take  place  in  thin  parts  of  over-distended  cysts.  A  tense, 
but  otherwise  healthy,  cyst-wall  may  be  ruptured  by  a  blow,  or 
even  by  rough  handling ;  and  in  such  a  case  the  immediate 
symptoms  may  be  very  acute  and  very  alarming.  The  rupture 
of  an  acutely  inflamed  or  suppurating  cyst  is  of  the  nature  of 
the  bursting  of  an  abscess  inside  the  peritoneal  cavity,  and  is 
immediately  followed  by  grave  and  alarming  symptoms. 

Haemorrhage  after  rupture  of  a  cyst  is  not  usually  severe. 
If  bleeding  is  free,  it  is  more  likely  to  arise  in  the  form  of  a 
passive  oozing  from  the  abundant  vessels  of  intra-cystic  papillo- 
matous growths,  than  from  the  torn  vessels  in  the  rent. 

Cysts  containing  papillomatous  growths  are  peculiarly  liable 
to  undergo  rupture — not  once  only,  but  several  times.  The 
immediate  danger  is  not  great,  because  the  free  flow  of  fluid  is 
prevented  by  the  villi  plugging  the  opening ;  but  the  remote 
danger  is  considerable  from  infection  of  the  peritoneum.  In 
multilocular  cystomata,  the  thin -walled  secondary  cysts  are 
most  liable  to  rupture.  Dermoid  cysts  usually  rupture  into 
some  neighbouring  cavity — bladder  or  rectum  most  frequently — 
rather  than  into  the  peritoneum. 

Twisting  of  the  Pedicle. — Rotation  of  ovarian  tumours,  result- 
ing, as  it  sometimes  does,  in  twisting  of  the  pedicle  and  stran- 
gulation of  its  vessels,  may  be  an  accident  of  serious  moment. 
Terillon  estimates  that  it  occurs  in  about  6  per  cent,  of  all  cases. 
Much  speculation  has  been  offered  as  to  its  cause.     Tait  very 

9 


114  OVARIOTOMY. 

ingeniously  seeks  to  explain  it  as  caused  by  repeated  small  dis- 
placements of  the  growth  round  its  axis,  through  the  passage  of 
the  faeces  along  the  sigmoid  flexure  and  rectum.  Slight  twisting 
may  produce  no  effects ;  but  the  result,  if  the  twisting  is  two, 
three,  or  more  times,*  may  be  atrophy,  rupture,  or  gangrene  of 
the  tumour.  Complete  detachment  is  rare.  Sometimes  the 
tumour  continues  to  live  while  remaining  free  in  the  cavity ; 
more  frequently  it  contracts  adhesions  with  neighbouring 
organs,  and  especially  with  the  omentum. 

In  many  cases  a  twisting  of  the  pedicle  is  attended  with  no 
symptoms.  In  such  the  pedicle  will  probably  be  long,  thin,  and 
lax.  Usually,  however,  with  pedicles  of  ordinary  conformation, 
signs  of  congestion  or  inflammation  are  present,  such  as  opacity 
and  want  of  lustre  in  the  cyst-wall,  with  extravasation  of  blood 
into  the  cyst-cavity.  The  haemorrhage  into  a  cyst  whose  pedicle 
has  been  twisted  may  be  so  considerable  as  to  produce  symp- 
toms of  loss  of  blood.  Inflammation  may  proceed  to  suppura- 
tion in  these  cases  ;  and  not  a  few  of  the  described  cases  of 
gangrene  have  been  attributed  to  twisting  of  the  pedicle. 

Doran,i  Chalot,]:  myself, §  and  others  have  recorded  some 
remarkable  cases  where  the  vitality  of  the  tumour  has  been 
maintained  by  adventitious  adhesions  after  the  pedicle  has  been 
twisted  through.  It  is  probable  that  many  dermoid  cysts  of 
the  abdomen  that  have  been  described  as  non-ovarian  are  really 
ovarian  cysts  that  have  been  separated  from  their  pedicles. 

Suppuration  in  Cysts. — Suppuration  in  the  growth,  attended, 
as  it  always  is,  with  acute  peritonitis,  is  a  most  serious  compli- 
cation. The  immediate  causes  of  suppuration  are  various : 
inflammation,  from  traumatism;  localised  gangrene;  strangu- 
lation of  the  pedicle,  from  twisting ;  introduction  of  septic 
matters  into  the  cystic  cavity,   from    tapping.      Inflammation 

*  See  Hunter  in  N.  Y.  Med.  Rec,  1885,  xxvii.,  p.  359. 

t  Med.  Clu'r.  Trans.,  vol.  Ixviii.,  1885. 

+  Atm.  de  Gyn.  et  d'Obst.     Mar.,  July,  1887. 

§  Brit.  Gynac.  Joiirn.,    Nov.,    1887 — where  there  is  a  full  description  of  the 

growth  with  drawings  by  Mr.  Bland  Sutton. 


ROKITANSKY'S   TUMOUR.  115 

in  the  cyst-wall  is  communicated  to  the  peritoneum,  and  may 
set  up  general  peritonitis  of  the  most  dangerous  character. 
Localised  inflammation  of  a  non-septic  nature  may  exist  in  a 
minor  secondary  cyst  without  producing  alarming  symptoms  t 
as  a  rule,  however,  suppuration  signifies  its  presence  in  an 
unmistakable  and  emphatic  manner. 

When  any  of  these  accidents  occur — suppuration,  twisting 
of  pedicle,  or  rupture — immediate  operation  is  indicated.  The 
danger  from  suppuration  is  greatest :  twisting  of  the  pedicle  is 
dangerous  chiefly  when  followed  by  congestion,  which  runs  oa 
to  gangrene  or  suppuration,  and  is  only  inferred  from  the  exist- 
ence of  such  inflammatory  disturbance ;  rupture  is  least  dan- 
gerous as  a  rule,  but  is  sometimes  rapidly  fatal.  In  all,  danger 
to  life,  immediate  as  well  as  remote,  is  lessened  by  operation, 
Keith  first  taught  us  how  to  deal  with  suppurating  cysts :  his- 
successful  teaching  has  been  extended  to  the  treatment  of  the 
other  accidents  to  which  pedunculated  cystic  growths  are  liable. 

Some  reference  must  be  made  to  that  peculiar  variety  of 
ovarian  cystoma  called  by  Tait  "  Rokitansky's  tumour."  It 
was  first  described  by  Rokitansky  as  a  special  variety  of  C3'S- 
toma ;  and  Ritchie  first  described  the  presence  of  ova  in  its 
cysts.  "  These  tumours  are  always  double,  no  case  having  yet 
been  described  as  having  occurred  on  one  side  only.  They  are 
always  of  very  slow  growth ;  their  cysts  are  uniformly  small^ 
rarely  reaching  the  size  of  an  orange,  and  generally  being  little 
bigger  than  grapes.  The  tumours  are  never  large,  and  it  is  only 
the  fact  that  both  ovaries  are  always  aff"ected  that  makes  them, 
objects  for  surgical  interference.  The  contents  of  the  cysts  are 
invariably  limpid,  and  the  ovum  may  nearly  always  be  found ; 
and  in  these  two  respects,  as  well  as  in  the  immense  number 
of  the  cysts,  the  tumours  differ  absolutely  from  ordinary^ 
cystoma." "  Tait  has  operated  upon  two  such  cases,  and  a 
preparation  from  one  of  his  cases  is  placed  in  the  Hunterian 
Museum.  A  full  account  of  this  rare  disease  is  given  in. 
Tait's  work. 

*  Tait,  Diseases  of  the  Ovaries,  p.  169,  1885. 
9  '■■• 


116  OVARIOTOMY. 


TAPPING    OVARIAN    CYSTOMATA. 


The  present  position  of  tapping  as  a  surgical  procedure  in 
ovarian  cystoma  is  rather  as  a  measure  for  temporarily  relieving 
symptoms,  than  as  a  plan  of  treatment.  As  an  aid  to  diagnosis, 
it  has  been  practically  discarded.  As  a  method  of  cure,  it  has 
long  been  accounted  futile.  And  even  as  a  means  of  ameliora- 
ting symptoms,  it  is  doubtful  if  the  combined  risks,  immediate 
and  remote,  are  not  often  as  great  as  those  following  complete 
removal  of  the  tumour. 

The  occasions  on  which  tapping  may  be  legitimately  adopted 
are  twofold :   firstly,  when  removal  of  the  growth  is  inadmis- 
sible ;   and  secondly,  when  the  patient  is  suffering  from  some 
incidental   ailment  which   renders   postponement  of  operation 
necessary.     In  the  first  case,  tapping  is  used  simply  to  promote 
euthanasia ;  in  the  second,  to  gain  time  for  improvement  of  the 
patient's  condition.     The  coincidence  of  any  grave  and  incur- 
able disease,  such  as  cancer,  phthisis,  or  advanced  disease  of 
the  heart,  or  in  fact   any  condition  which  negatives  surgical 
operation  of  any  sort,  negatives  ovariotomy.    Here  tapping  may 
be  advisable,  to  prolong  life  or  to  render  it  less  painful.     On  the 
other  hand,  if  a  patient  is  suffering  from  an  acute  disease — such 
as  bronchitis,  or  pneumonia,  or  typhoid  fever — which  negatives 
ovariotomy,  and  the  progress  of  which  is  likely  to  be  favourably 
influenced  by  relieving  a  distended  abdomen,  tapping  is  expe- 
dient.     Also  in  chronic   complaints,   such   as   bronchitis  with 
dyspnoea,  tapping  may  contribute  to  the  patient's  improvement, 
and  so  increase  the  chances  of  success  for  the  major  operation. 
"When  the  renal  functions  are  upset,  or  when  there  is  oedema  of 
the  limbs  from  pressure,  or  generally  where  the  condition  of  the 
patient  is  deteriorated  by  the  existence  of  intra-abdominal  pres- 
sure, tapping  may,  by  temporarily  removing  this  pressure,  cause 
material  improvement  in  the  patient's  condition. 

The  operation  must  be  conducted  with  a  supreme  regard  to 
antiseptic  purity.  The  skin  at  the  site  of  puncture  must  be 
thoroughly  cleansed ;  and  the  instrument,  inside  as  well  as 
outside,  must  be  perfectly  pure.     The  antiseptic  trocar  of  Ward 


TAPPING   OVARIAN  CYSTS. 


117 


Fig.  17. 


Cousins  is  a  very  suitable  instrument  for  the  pur- 
pose ;  and  the  blunt  ascites  tubes  of  Tait  and  of 
Wells  (Fig.  17)  would  leave  nothing  to  be  desired, 
if  they  did  not  require  previous  puncture  of  the 
abdominal  walls  by  lancet — a  necessity  which 
many  would  consider  a  disadvantage.  The  exact 
nature  of  the  instrument  matters  little,  provided 
it  be  small,  simple,  and  as  nearly  as  possible  a 
closed  tube.  It  ought  not  to  be  larger  than  a 
No.  6  English  catheter.  A  large  trocar  is  doubly 
objectionable,  as  causing  a  large  opening  in  the 
cyst-wall,  which  may  leak  ;  and  as  permitting  too 
rapid  a  flow  of  fluid,  which  may  cause  shock  to 
the  patient.  A  long  rubber  tube  is  attached  to  the 
end  of  the  cannula,  and  conducts  the  fluid  into  a 
suitabl}'  placed  receptacle.  Bandages  to  compress 
the  abdomen  are  quite  unnecessary.  The  patient 
lies  on  her  side  near  the  edge  of  the  bed,  and  the 
trocar    is    inserted  at   a    suitable   place,    usually 


Wells's  Ascites  somewhere  in  [the  middle  line,  between  the  um- 

,^  ,,   :  bilious  and  pubes.     The  end  of  the  rubber  tube 

Half  size.        _  -^  _  _ 

is  kept  under  carbolic  lotion,  and  never  removed 
therefrom,  as  air  is  liable  to  enter.  A  piece  of  glass  tubing 
inserted  in  the  middle  of  the  rubber  tube  will  show  whether 
fluid  continues  to  flow.  When  the  cannula  is  removed  the 
opening  is  pinched  between  the  fingers,  and  the  tissues  moved 
about,  so  as  to  destroy  the  continuity  of  the  perforation.  A 
small  piece  of  lint,  soaked  in  collodion,  is  sufficient  to  close 
the  opening.  A  binder  relieves  the  uncomfortable  sense  of 
emptiness  which  usually  remains  after  relief  of  abdominal 
tension. 

Conducted  properly,  the  operation  of  tapping  is  attended 
with  very  slight  risks.  It  is  just  possible  that  the  disrepute  into 
which  the  proceeding  has  fallen  is  to  be  attributed  to  careless 
manipulation  or  unclean  instruments.  Men  who  have  not 
before  their  eyes  a  complete  foreknowledge  of  its  possible  effects 
are  liable  to  have  recourse  to  tapping  on  every  occasion  when 


118  OVARIOTOMY, 

they  have  a  patient  suffering  from  fluid  distension  of  the 
abdomen,  and  such  men  are  not  Hkely  to  take  full  scientific 
precautions. 

HISTORY    OF    OVARIOTOMY. 

The  history  of  ovariotomy  reads  almost  Hke  a  romance. 
From  being  dreamed  of  as  a  remote  possibihty  by  advanced 
thinkers  some  century  and  a  half  ago  in  the  capitals  of  Europe, 
and  attempted  by  one  or  two  daring  enthusiasts,  it  first  reached 
its  consummation  as  a  definite  schemed  operation  far  away  from 
the  centres  of  civilisation.  In  Great  Britain,  as  in  its  birth- 
place, America,  the  operation  had  struggled  into  existence  and 
was  thriving  in  the  provinces,  before  it  had  established  a  footing 
in  the  capital.  It  was  true  of  this,  as  of  so  many  other  im- 
provements in  practical  surgery,  that  it  owed  its  birth  to  the 
freedom  and  independence  of  the  provincial  mind  :  the  spirit  of 
the  pioneer  had  certainly  entered  the  soul  of  Ephraim  McDowell, 
almost  in  the  backwoods  of  Kentucky. 

There  is  no  doubt  but  that  some  form  of  mutilation  of  the 
female  sexual  organs  has  been  practised  from  the  most  ancient 
times.  In  most  instances  this  was  probably  removal  of  some 
parts  of  the  external  organs  of  generation ;  in  some,  however,  it 
would  appear  certain  that  the  ovaries  were  actually  removed. 
This  .was  essentially  female  castration,  or  spaying  ;  and  the 
removal,  in  righteous  anger,  of  the  ovaries  of  his  unchaste 
daughter  by  the  Hungarian  sow-gelder,  two  centuries  ago,  is 
probably  the  last  operation  of  this  sort  known  to  history.  Such 
operations,  demonstrating,  as  they  did,  the  possibility  of 
removing  ovaries  that  were  healthy,  were  probably  not  without 
their  value  in  clearing  the  way  for  the  removal  of  ovaries  that 
were  diseased.  The  value  of  such  operations,  however,  will  be 
best  estimated  in  considering  the  operation  of  oophorectomy. 

To  the  active  and  enquiring  minds  of  many  surgeons  living 
in  the  early  parts  of  the  eighteenth  century,  the  possibility 
of  removing  cystic  ovaries  was  often  presented.  Willius  of 
Basle,  in  1731,  spoke  perhaps  most  clearly  in  favour  of  the 
operation,   though    he    had    not    the    courage   to   attempt    it. 


HISTORY.  119 

Delaporte*  actually  treated  an  ovarian  cyst  by  incision  through 
the  abdominal  wall,  but  did  not  remove  it.  Morand,  who 
follows  up  Delaporte's  paper  in  the  same  volume  by  some 
remarks  of  his  own,  desires  to  give  the  latter  credit  for  having 
been  the  first  definitely  to  propose  the  removal  of  an  ovarian 
cyst,  and  expresses  his  own  opinion  that  the  operation  is 
feasible,  provided  there  be  no  adhesions.  Hunter,  in  1762, 
with  the  far-seeing  genius  which  we  now  fully  appreciate, 
actually  suggested  the  small  incision,  tapping  the  cyst,  re- 
moving it,  and  ligaturing  the  pedicle.  A  Russian  surgeon 
named  Segdel  is  said  to  have,  in  1784,  begun  an  operation  with 
the  view  of  removing  what  he  believed  to  be  an  ovarian  tumour; 
it  turned  out,  however,  to  be  a  distension  of  the  Fallopian  tube 
with  pus,  which,  being  unable  to  remove  on  account  of  adhe- 
sions, he  simply  incised  and  drained.!  The  surgeon  who  came 
nearest  to  being  the  first  ovariotomist  was  Chambon,  who,  in 
1798,  published  in  Paris  a  treatise  on  The  Diseases  of  Women, 
wherein  he  strongly  recommended  the  removal  of  diseased 
ovaries.  He  gave  accurate  accounts  of  the  anatomy  of  cystic 
tumours  of  the  ovaries,  and  tried  to  show  how  to  diagnose 
adhesions,  and  how  to  deal  with  them.  John  Bell,  no  doubt 
familiar  with  the  work  of  French  surgeons,  constantly  dwelt  in 
his  lectures  on  the  possibility  and  the  advisability  of  removing 
such  tumours,  and  his  teachings  bore  fruit  ;  for  one  of  his 
pupils,  Ephraim  Mc  Dowell,  was  the  first  ovariotomist. 

The  claims  of  Mc  Dowell  of  Kentucky  to  be  considered  as 
the  first  surgeon  who  deliberately  and  scientifically  planned  and 
performed  the  operation  of  removal  of  an  ovarian  tumour  are 
now  established  beyond  dispute.  The  operation  of  Houston  of 
Glasgow  was  almost  certainly  not  a  complete  ovariotomy,  j  and 

*  Mem.  de  I'Acad.  Roy.  de  Chir.,  torn.  ii. ;  Paris,  1753. 

'   ,  t  New  York  Med.  Journ.,  Feb:  nth,  i88g. 

§  It  is  right  to  say  that  Tait,  who  has  made  special  enquiries  into  the 
subject  {Dis.  of  Ovaries,  1883,  p.  239),  claims  for  Houston  the  honour  of 
having  been  the  first  ovariotomist.  Now,  an  ovariotomy  is  not  complete 
unless  the  tumour  is  removed  and  the  pedicle  is  secured.  In  Houston's 
account  of  his  case  there  is  not  a  suggestion  that  he  did  either.  It  seems  to 
me   scarcely   credible  that  a  surgeon   who   could   describe,  as  minutely  as 


120  OVARIOTOMY. 

those  of  Lammonier  of  Rouen,  Dzondi  of  Halle,  and  Galenzowskj'- 
of  Wilna,  even  if  they  had  been  ovariotomies,  which  they  were 
not,  were  performed  subsequently  to  the  first  operation  of 
McDowell.  In  December,  1809,  McDowell  operated  on  Mrs. 
Crawford,  and  seven  years  later  he  published  his  report  of  this 
and  two  other  operations.  In  America,  the  operation  thus 
initiated  was  taken  up  by  Dunlap  of  Ohio,  by  Nathan  Smith 
of  Connecticut,  by  Alban  Smith  of  Kentucky,  by  Gallup  of 
Vermont,  and  by  many  others.  Up  to  the  end  of  1863,  accord- 
ing to  Peaslee,*  ovariotomy  had  been  reported  as  performed  in 
America  117  times,  with  68  recoveries  and  49  deaths.  Since 
then,  American  surgeons  have  taken  a  prominent  and  honour- 
able share  in  perfecting  the  operation,  which  is  now  performed 
everywhere  throughout  the  Continent. 

In  Great  Britain,  the  operation  did  not  at  first  make  much 
progress.  Lizars  operated  in  Edinburgh  once  in  1824,  and 
three  times  in  1825,  but  with  such  small  success  that  Listen 
boasted  that  he  took  good  care  that  Lizars  did  not  set  about  any 
such  operation  in  the  Infirmary  after  he  became  attached  to  it. 
The  medical  papers  of  those  days  were  also  dead  against  the 
operation ;  and  few  attempts  and  an  equal  number  of  failures 
were  recorded  till  1836,  when  William  Jeaffreson,  a  surgeon  of 
Framiingham,  operated  successfully  by  the  small  incision.  In 
the  same  year.  King  of  Saxmundham  had  a  successful  operation ; 
and  in  1839,  West  of  Tonbridge  had  two  successes.  A  few 
London  surgeons  operated  in  the  next  year  or  two,  in  every  case 
unsuccessfully.  The  thread  of  success  was  then  picked  up  by 
Charles  Clay  of   Manchester   in    1842,  who,  in   the   words   of 

Houston  did,  the  somewhat  trivial  expedient  adopted  for  removing  the  glairy- 
fluid  should  leave  unmentioned  the  far  more  important  proceeding  of  removing 
the  tumour,  and  dividing  and  securing  the  pedicle.  "  I  then  squeezed  out  all 
I  could  [of  the  contents],  and  stitched  up  the  wound  in  three  places."  If 
between  the  squeezing  and  the,  stitching  the  grand  measures  of  removing  the 
tumour  and  securing  its  pedicle  really  did  occur,  I  think  he  must  have  at 
least  mentioned  them.  Houston  says  the  tumour  was  of  the  left  ovary,  but 
the  only  proof  he  adduces  in  support  of  this  is  that  it  lay  on  the  left  side.  The 
after-history  of  the  case  is  in  no  way  inconsistent  with  his  having  incised  an 
ovarian  growth. 

*  Ovarian  Tmnours,  p.  247 ;  London,  1873. 


HISTORY.  121 

Peaslee,  "soon  became  the  most  successful  ovariotomist  living," 
and  to  whom,  "  more  than  to  all  other  operators,  the  credit 
belongs  of  having  placed  the  operation  of  ovariotomy  on  a  sure 
foundation."  Up  to  1850,  eight  years  before  Spencer  Wells 
began  to  operate,  he  had  chronicled  twenty-one  successes  out  of 
thirty-three  operations — a  result  more  favourable  than  Wells 
could  show  in  the  same  number  of  cases,  not  finished  till  twelve 
years  later.  Between  1852  and  1856,  Baker  Brown  operated 
nine  times,  with  seven  deaths.  This  mortality  checked  him  for 
four  years,  when  he  began  a  career  which,  but  for  its  untimely 
and  unfortunate  termination,  would  probably  have  done  much 
for  ovariotomy. 

The  year  1858  brings  us  to  the  beginning  of  the  remarkable 
career  of  Spencer  Wells.  Commencing  with  a  promise  faithfully 
to  record  every  case,  successful  or  unsuccessful,  upon  which  he 
operated,  he  has  pursued  this  course  to  the  present  day,  when 
he  has  well  passed  the  thousand.  Round  his  personality  centred 
all  the  changes,  improvements,  and,  we  must  add,  retrogressions, 
which  have  followed  the  fortunes  of  the  operation.  His  hearty 
readiness  to  try  the  recommendations  of  others,  though  it  has 
not  always  been  conducive  to  reduced  mortality,  has  testified  to 
his  honesty  of  purpose  and  breadth  of  view. 

The  next  prominent  figure  in  ovariotomy  is  that  of  Thomas 
Keith  of  Edinburgh.  In  1865  he  performed  his  first  ovariotomy, 
and  he  very  soon  proved  himself  the  most  skilful  of  all.  To-day 
some  of  his  operations,  such  as  those  for  removal  of  large 
fibroids,  seem  almost  to  have  reached  the  limits  of  successful 
human  surgery. 

And,  among  those  who  have  more  recently  entered  the  field, 
the  brilliancy  of  results  seems  still  to  be  on  the  increase.  Tait 
of  Birmingham  has  attained  to  a  success  which  is  as  remarkable 
as  it  is  well  deserved.  He  can  show  the  extraordinary  record 
of  one  hundred  and  thirty-nine  ovariotomies  without  a  death,  a 
result  which  could  scarcely  be  shown  for  the  most  trivial  surgi- 
cal operation.  At  the  Samaritan  Free  Hospital,  in  London,  the 
mantle  of  Wells  has  worthily  fallen  on  the  shoulders  of  Thornton 
and  of  Bantock.     On  the  Continent,  the  names  of  Koeberle, 


122  OVARIOTOMY. 

Schroeder,  Billroth,  Martin,  and  a  host  of  others,  are  honour- 
ably associated  with  the  operation.  And  all  over  the  civilised 
world,  in  every  capital,  town,  and  village,  there  are  surgeons 
who,  with  honour  to  their  art  and  credit  to  themselves,  success- 
fully perform  the  operation,  which  half  a  century  ago  was 
condemned  by  the  leaders  of  surgery  as  being  little  removed 
from  murder. 


APPRECIATION.  INDICATIONS    FOR    OPERATION. 

Ovariotomy  is  the  most  successful  major  operation  in  surgery. 
Within  the  memory  of  living  surgeons  its  mortality  has  dimin- 
ished from  what  was  almost  the  limit  of  the  justifiable  in 
surgery,  to  a  figure  which,  as  statistics  are  estimated,  is  practi- 
cally zero.  Our  best  English  operators — Keith,  Thornton, 
Bantock,  and  others — in  the  last  few  years  had  brought  their 
death-rate  down  to  the  marvellously  low  figure  of  about  ten  per 
cent.,  more  or  less,  when  Lawson  Tait's  records  beat  all,  by  the 
extraordinary  result  of  one  hundred  and  thirty-nine  cases  with- 
out a  death,  and  a  general  mortality  over  several  hundreds  of 
cases  of  less  than  five  per  cent.  Keith's  recent  mortality,  in 
private  operations  with  cautery-clamp,  is,  he  tells  me,  under  two 
per  cent.  Surely  this  is  the  7ie  plus  ultra,  not  only  of  abdominal 
surgery,  but  of  all  surgery.  If  it  is  not  a  justification  for  the  per- 
formance of  ovariotomy,  wherever  an  ovarian  tumour  exists,  it 
is  undoubtedly  a  stern  command  to  all  who  seek  to  perform  the 
operation,  so  as  to  give  their  patients  the  best  chance  of  life,  to 
spare  no  pains  to  perfect  themselves  in  every  detail  of  attainable 
knowledge. 

With  such  prospects  of  recovery,  it  would  seem  that  little 
more  than  the  diagnosis  of  ovarian  cystoma  was  necessary  to 
justify  operation.  Excluding  the  just  and  proper  contra-indica- 
tions  to  this  or  any  other  serious  surgical  operation,  and  which 
need  not  here  be  mentioned,  there  is  scarcely  a  condition  in  the 
tumour  itself  which  absolutely  forbids  operation.  The  only 
question  is  as  to  the  best  time  for  operating.  The  futility  of  all 
modes  of  medical  or  incomplete  surgical  treatment  has  long  been 


OVARIOTOMY  DURING    PREGNANCY.  123 

admitted ;  complete  removal  alone  gives  certain  recovery.  When 
twenty  or  thirty,  or  even  forty  per  cent,  of  the  cases  operated 
upon  died,  there  was  some  justification  for  the  postponement  of 
the  operation  till  such  time  as  the  patient's  health  and  comfort 
were  being  interfered  with.  But  with  such  mortality  as  the 
operation  now  gives  in  the  best  hands,  this  position  is  scarcely 
tenable;  in  fact,  it  has  been  quietly  given  up.  The  rule  is  now  to 
operate  early — as  soon,  in  fact,  as  the  existence  of  the  tumour  has 
been  proved.  The  arguments  in  favour  of  early  operation  need 
not  here  be  dilated  upon.*  Suffice  it  to  say  that,  as  there  is  but 
one  escape  from  the  disease,  by  removal ;  and  as  delay  involves 
the  risks  of  changes  and  accidents  in  the  tumour,  of  secondary 
disease  in  other  organs,  and  of  general  impairment  of  health, 
it  is  right  that  the  operation  should  be  performed  as  early  as 
possible. 

The  question  of  ovariotomy  during  pregnancy  can  scarcely 
be  answered  in  general  terms.  A  good  many  successful  ovari- 
otomies performed  during  pregnancy  have  been  recorded  ;  and 
many  examples  of  healthy  gestation,  followed  by  normal  partu- 
rition, going  on  side  by  side  v/ith  the  growth  of  an  ovarian 
tumour,  could  be  quoted.  W.  W.  Potterf  of  Buffalo  has  per- 
formed a  double  ovariotomy  for  cystic  disease — the  two  tumours 
weighing  thirty-eight  pounds — during  the  fourth  month  of  preg- 
nancy, and  the  patient  went  to  full  term  and  was  normally 
delivered  of  a  healthy  child.  Ovarian  cystoma  no  doubt  pre- 
disposes to  abortion,  and  other  dangers  of  the  pregnant  state ; 
and  pregnancy  renders  more  likely  the  ordinary  accidents  to 
which  cystoma  is  liable.  Each  case  must  be  judged  on  its 
merits.  The  points  specially  to  be  attended  to  are  :  the  rapidity 
of  the  growth  of  the  tumour,  the  period  of  gestation,  and  the 
condition  of  the  patient.  A  tumour  of  rapid  growth,  discovered 
in  the  early  stages  of  pregnancy,  might  be  removed,  when 
another  of  slow  growth,  large,  and  possibly  difficult  of  removal, 
might  be  tapped,  particularly  if  the  expected  time  of  delivery 

*  See  Dr.  Bsintock's  Plea  for  Early  Ovariototny.    London,  1881. 
t  Amer.  Journ.  Obstet.,  Oct.,  1888. 


124  OVARIOTOMY. 

was  close  at  hand.     Beyond  these  general  statements,  it  would 
be  unwise  to  dogmatise. 

THE    OPERATION    OF    OVARIOTOMY. 

Preliminary. — The  patient  will  have  been  prepared  according 
to  the  general  directions  already  given.  Her  bowels  will  have 
been  opened  by  aperient,  and  she  will  have  passed  water 
immediately  before  the  hour  fixed  for  operation.  She  is  placed 
on  the  operating  table,  dressed  in  a  flannel  jacket,  and  her 
limbs  are  covered  by  warm  blankets  or  surrounded  in  cotton 
wool ;  and,  if  deemed  expedient,  a  layer  of  cotton  wool  is  laid 
over  the  chest  and  abdomen,  up  to  the  limits  of  the  opening  in 
the  macintosh  sheet.  The  sheet  is  placed  in  position  so  that 
the  hole  leaves  exposed  the  site  of  operation,  and  elsewhere 
completely  covers  the  patient,  and  hangs  over  the  edges  of  the 
operating  table.  The  adhesive  material  spread  round  the 
margin  of  the  opening  keeps  the  sheeting  closely  in  contact 
with  the  skin  on  the  parietes.  The  exposed  skin  and  the  mac- 
intosh around  are  once  more  cleansed  with  carbolic  lotion,  and 
a  sponge-cloth  wrung  out  of  1-40  carbolic  lotion  is  laid  over  the 
macintosh  covering  the  thighs,  which  will  have  been  confined 
by  a  broad  bandage.  The  spray  is  placed  opposite  the 
patient's  left  shoulder,  at  a  distance  of  six  feet  or  more  from 
the  wound.  This  position  is  selected  so  that  the  patient 
shall  not  respire  a  carbolised  atmosphere.  A  receiver,  to 
collect  the  fluid,  is  placed  at  the  side  of  the  table  next  to  the 
operator. 

Assistance. — Besides  the  anaesthetist,  one  assistant  is  all  that 
is  necessary.  His  special  duties  will  be,  to  sponge,  to  manipulate 
forceps  during  the  application  of  ligatures,  and  to  help  during 
the  deligation  of  the  pedicle  and  the  suturing  of  the  abdominal 
wound ;  besides  these,  he  will  be  frequently  called  upon  to 
discharge  other  minor  functions,  too  numerous  to  be  mentioned. 
A  nurse  will  be  wanted,  to  cleanse  and  hand  sponges,  and  to 
see   to   the   provision   of  hot   water,  lotions,   and   such   minor 


INSTRUMENTS. 


125 


necessities.  The  operator  helps  himself  to  instruments, 
which  are  placed  in  trays  upon  a  table  placed  conveniently 
within  the  reach  of  his  right  hand.  The  assistant  stands 
on  the  left  side  of  the  patient,  facing  the  operator.  (See 
Fig  5-) 

Instnmients. — The   following   instruments   are   recommended 
for  the  performance  of  ovariotomy  : 


Tait's  haemostatic  pressure  forceps 

Thornton's  T-shaped  pressure  forceps 

Wells's  large  cyst  forceps — angular  and  straight 

Wells's  medium  cyst  forceps    

Nelaton's  cyst  forceps        

Knife      

Scissors         

Pedicle  needles,  in  handles,  blunt    

Cyst  trocar,  with  tubing,  Tait's  large  (Fig.  20) 
,,         ,,         Spencer  Wells's,  with  Fitch's  dome 

(Fig.  21)        

Suture  instrument       

Reel-stand  with  silk  ligatures 


12 
2 
4 

4 
2 
I 
I 
2 
I 

I 
I 
I 


With  these  instruments  most  ovariotomies  may  be  satis- 
factorily performed.  In  routine  operating,  they  are  laid  out  in 
three  trays  containing  enough  carbolic  lotion  to  cover  them. 
One  tray  contains  the  small  haemostatic  forceps,  fourteen  in 
number;  another,  of  larger  size,  contains  the  large  and  medium 
cyst  forceps,  ten  in  number  ;  while  the  third  contains  the  knife, 
scissors,  pedicle  needle,  and  suture  instrument.  The  trocars, 
with  tubing  attached,  are  kept  apart,  in  a  large  basin.  The 
ligature  silk,  of  assorted  sizes  of  finest  Chinese  twist,  is  kept  on 
reels  in  carbolic  lotion — the  reel-stand  already  described  (Fig.  4) 
is  very  convenient  for  this  purpose — and  ligatures  cut  off  as 
they  are  wanted. 

These,  or  similar  instruments,  are  absolutely  essential ;  but 
few  surgeons  would  care  to  begin  operation  without  several  other 


126  OVARIOTOMY. 

instruments  being  at  hand,  in  case  they  were  wanted.     Among 
these  might  be  mentioned  : 

Koeberle's  clamp,  with  pedicle  skewers. 

Cautery  irons.     (Paquelin's  thermo-cautery  requires 

a  separate  assistant.) 
Six  Keith's  glass  drainage  tubes — assorted  sizes. 
A  second  dozen  of  pressure  forceps. 
Two  retractors. 
Silk-worm  gut  sutures. 

Each  operator  will  probably  like  to  have,  in  reserve,  a  few 
special  instruments  to  which  he  has  become  accustomed :  the 
writer,  for  instance,  never  likes  to  be  without  his  crushing 
scissors.  A  Lister's  sinus  forceps,  with  points  a  little  sharper 
than  ordinary,  is  an  excellent  substitute  for  the  needle  which 
carries  the  ligature  through  the  pedicle :  the  point  is  pushed 
through,  the  blades  are  separated,  and  they  catch  the  ligature 
thread  and  draw  it  backwards  through  the  opening  made. 
Many  surgeons  use  a  director  and  a  dissecting  forceps.  Special 
instruments  for  crushing  the  pedicle  before  tying  it ;  an  ex- 
hausting air-pump,  attached  to  the  trocar ;  peculiar  needles  for 
suturing  the  abdominal  wound,  and  many  other  appliances,  are 
in  vogue ;  but  the  above  may  be  taken  fairly  to  represent  the 
instrumental  aids  necessary  to  a  skilful  performance  of  the 
operation. 

Some  of  the  instruments  require  special  description.  Tait's 
pressure  forceps  (Fig.  6) — a  modification  of  Koeberle's — is 
superior  to  Wells's  instrument  in  being  more  pointed,  thus 
permitting  the  ligature  to  slip  over  it  in  tying  adhesions, 
and  in  being  more  powerful  in  grasp.  In  other  respects,  the 
instruments  are  practically  identical.  Thornton's  T-shaped 
forceps  is  a  most  useful  addition  to  our  haemostatic  agents. 
It  is  scissors-handled  like  the  other  catch  forceps,  with  a 
rack  catch,  but  differs  in  having  the  compressing  blades  set 
at  right  angles  to  the  handle.  For  holding  broad  adhesions, 
or  compressing  a  piece  of  omentum  which  has  to  be  secured 
with    multiple    ligature,    or   closing    a   small    rent    in   a   cyst. 


INSTRUMENTS. 


127 


Thornton's  instrument  is  simply  invaluable.  I  have  found  a 
very  large  forceps  on  the  same  principle  most  useful  for  like 
purposes.  For  firmly  grasping  and  holding  the  tumour  itself, 
the  cyst  forceps  of  Nelaton  (Fig  i8)  and  of  Spencer  Wells  leave 
nothing  to  be  desired.  Nelaton's  forceps,  with  its  round, 
serrated,  and  spiked  biting  surfaces,  maintains  a  grasp  on  the 
cyst-wall  which  is  as  powerful  as  the  area  it  grasps  can  make  it. 
Wells's  large  cyst  forceps,  on  the  same  principle  as  his  small  pres- 
sure forceps,  is  perhaps  less  likely  to  cause  tearing,  and  holds 

nearly  as  firmly  as  Nelaton's. 
It  is  made  with  straight  and 
with  bent  blades.  (Figs.  7,  8,  10.) 
A  size  of  Wells's  forceps  midway 
between  the  smallest  and  the  lar- 
gest will  be  found  very  handy. 
Wells's  clamp  forceps  (Fig.  ig) 
may  occasionally  be  found  useful 
for  closing  rents  in  the  cyst,  or 
for  compressing  large  bleeding 
areas.  The  only  advantage  which 
they  pos- 
sess over 
large 
sure 


pres- 
for- 


FiG.   18. 
Nelaton's  Cyst  Forceps,     Half  size. 


ceps  is  that 
they  oc- 
cupy less 
room. 

For  evac- 
uating the 
fluid,  we 
have  a 
choice  of 
many  tro- 
cars. It  is 
wise  to 
have    two 


Fig.  19. 

Wells's  Clamp  Forceps. 
One-third  size. 


128 


OVARIOTOMY. 


instruments  in  readiness  —  one  of 
large  size,  and  another  not  very  large. 
The  two  I  should  select  are  Tait's 
large  instrument  (Fig.  20),  with  conical  but  not  cutting 
point,  and  Wells's  (or  Fitch's)  small  instrument  (Fig. 
21),  which  is  essentially  a  double  tube,  the  outer  one  of 
which  is  the  trocar — sharp  and  pointed,  and  the  inner 
one  is  the  cannula — blunt  and  extrusible.  For  a  large 
thick-walled  cyst,  Tait's  trocar  is  best.  Wells's  small 
puncturing  trocar  is  suitable  for  small  and  multilocular 
cysts,  and  for  those  which  have  thin  walls.  Some 
amount  of  fluid  usually  escapes  by  the  side  of  it ;  but 
this  may  either  be  collected  by  a  sponge,  or  its  flow  may 
be  checked  by  the  pressure  of  a  large  cyst  forceps. 

Wells's  large  trocar  (Fig.  22)  is  used  by  many  sur- 
geons.    It  consists  of  an  outer  tube  or  trocar  proper, 
cut  obliquely    and  sharp  at  the   point,    for 
piercing,  and  an  inner  tube  or  cannula,  blunt 
■p  and  cut  square,  which  is  pushed  be- 

yond   the    trocar   by    an    attached 
Tait's  Cyst  Trocar.        ,         ,       .  "^  , 

One-third  size.        thumb-piece   as  soon  as   the    cyst- 
wall  is  pierced.     To  the  sides  of  the 
trocar  are  attached  two  spring  hooks  or  clasps,  with 
sharp  teeth  which  fit  into  pits  on  the  trocar;  these 
are  intended  to  grasp  the  cyst-wall  and  pull  it  for- 
ward   as    the    cyst    empties.      Volsella  are   usually 
required  to  pull  the  wall  of  the  cyst  under  the  hooks 
on  the  trocar.     To  the  trocar   is    fitted   a  piece   of 
india-rubber  tubing  of  a  calibre  as  large  as  that  of 
the  instrument,  and  long  enough  to  reach  the  bottom 
of  the  vessel  which  is  intended  to  receive  the  ovarian 
fluid.    A  dozen  sponges  are  pre- 
pared ready  for  use.    They  are 
selected  as  follows :  one  large 
flat   sponge;    four   moderately  Fig.  21. 

flat   sponges,  about  six  inches       ^y^j^^,^  ^mall  Cyst  Trocar,  with  Fitch's 
long   and   from   three   to    five  Dotn,^.    Half  size. 


THE  ABDOMINAL   INCISION. 


129 


inches  broad  ;  and  seven  round  sponges,  of  various  sizes.  They 
are  kept  in  warm  1-40  carbolic  lotion,  and  wrung  out  of  this  fluid 
by  the  nurse  or  assistant  when  required.  As  they  are  soiled  they 
are  handed  to  the  nurse,  who  cleanses  them  thoroughly  in  warm 
water,  and  then  places  them  in 
the  warm  carbolic  lotion.  A  con- 
tinuous supply  of  clean  sponges 
is  thus  provided. 

For  use  in  ovariotomy,  and  indeed  in  all 
other  surgical  operations,  I  become  daily  more 
impressed  with  the  value  of  sponge-cloths  for 
many  purposes  for  which  sponges  are  used. 
They  are  thick,  very  soft,  have  great  absorbing 
powers,  and  are  very  easily  cleansed.  Most 
important  of  all,  they  are  improved  by  being 
boiled,  whereas  boiling  destroys  sponges.  Laid 
over  the  abdominal  wound  under  a  bleeding 
tumour ;  coiled  around  a  piece  of  intestine 
while  it  is  being  sutured  ;  folded  over  omentum 
which  has  been  stripped  off  a  tumour,  and  in 
many  similar  ways,  sponge-cloths  will  be  found 
very  useful. 

The  Abdominal  Incision. — The  incision  is  made 
in  the  middle  line  between  the  umbilicus  and 
the  pubes.  The  structures  divided  are :  the 
skin,  the  subcutaneous  fatty  layers,  the  linea 
alba,  the  layers  of  the  fascia  transversalis  with 
the  subperitoneal  fat,  and  the  peritoneum.  The 
skin  in  this  region  does  not  usually  present 
features  of  special  practical  interest.  It  may  be  firm  and 
resilient,  and  intimately  adherent  to  the  subcutaneous  fat ; 
or  it  may  be  flaccid  and  soft,  and  readily  movable  over  the 
underlying  tissues.  In  the  former  case  it  is  easily  divided  in  a 
straight  line  by  the  knife  held  in  the  first  position  ;  in  the  latter 
case,  it  may  run  before  the  knife,  and  will  be  most  satisfactorily 
divided  by  pinching  it  up  and  transfixing  it,  as  in  herniotomy. 

10 


Fig.  22. 

Wells's  Large  Cyst 

Trocar. 

One-third  size. 


130  OVARIOTOMY. 

The  thickness  of  the  subcutaneous  fatty  layer  varies  very  con- 
siderably. In  cases  where  there  is  much  emaciation,  it  may  be 
practically  absent — the  first  incision  exposes  the  fibrous  aponeu- 
roses ;  in  very  stout  individuals,  the  subcutaneous  fat  may  be 
several  inches  in  thickness.  The  thickness  of  this  layer  may 
be  increased  by  oedema.  In  most  cases  the  subcutaneous 
areolar  tissue  is  divisible  into  two  layers.  The  outer  layer  is 
pre -eminently  fatty ;  the  inner,  mainly  fibrous.  Only  in  young 
subjects,  however,  is  this  distinction  well  marked.  The  vessels 
ramify  chiefly  in  the  outer  fatty  layer ;  usually  they  are  quite 
small,  but  sometimes  a  moderately  large  branch  is  divided. 
The  veins  are  occasionally  large  and  tortuous,  and  sometimes 
bleed  so  freely  after  division  as  to  require  forcipressure  or  even 
deligation. 

The  linea  alba  is  a  structure  of  fairly  constant  composition 
and  thickness.  In  muscular  individuals  with  small  tumours, 
the  recti  lie  quite  close  to  each  other,  and  the  linea  alba  is  then 
little  more  than  a  fibrous  partition ;  in  thin  subjects  whose 
abdominal  walls  are  distended,  the  linea  alba  may  be  stretched 
so  that  the  recti  are  separated  by  half  an  inch  or  even  more. 
In  the  latter  instance,  it  is  easy  enough  to  divide  the  linea  alba 
without  opening  the  sheath  of  the  rectus ;  in  the  former,  this 
is  a  matter  of  some  difficulty,  and  in  practice  one  or  both 
sheaths  are  frequently  opened.  Indeed,  in  some  cases  the 
linea  alba  is  so  narrow  that  division  of  it  accurately  in  the 
middle  line  must  result  in  exposure  of  both  muscles.  It  must 
be  remembered  that  the  posterior  wall  of  the  sheath  of  the 
rectus  stops  short  at  the  falciform  edge,  and  that  the  aponeu- 
roses of  the  muscles  below  this — in  the  lowest  fourth,  that  is 
to  say — all  pass  in  front  of  the  recti.  If  the  sheath  is  opened 
above  this  point,  an  additional  layer  of  fascia,  the  posterior 
wall  of  the  sheath,  has  to  be  divided  before  the  subperitoneal 
fat  is  reached ;  below  this  point  there  is  no  additional  layer,  or 
only  a  thin  fascia.  As  a  matter  of  fact,  the  cavity  is  usually 
entered  below  the  falciform  edge;  and  if  the  opening  is  too 
small,  it  is  extended  upwards  with  scissors,  when  no  account  is 
taken  of  anatomical  layers. 


THE  ABDOMINAL   INCISION.  131 

If  the  incision  has  to  be  carried  above  the  umbilicus,  it  is 
wise  to  deviate  a  httle  way  to  the  left,  and  not  to  pass  through 
it.  This  is  done  partly  to  avoid  the  round  ligament  of  the  liver, 
which  passes  from  the  umbilicus  obliquely  upwards  and  to  the 
right,  and  may  contain  an  unobliterated  umbilical  vein,  but 
chiefly  because  the  tissues  in  the  umbilical  area  are  thin  and 
liable  to  be  cut  through  by  the  sutures  if  there  is  straining  from 
sickness.  Such  an  accident  happened  to  me  in  a  case  of 
hysterectom3^  and  a  large  coil  of  intestine  escaped.  Fortunately 
the  accident  was  soon  discovered  and  no  harm  was  done.  The 
urachus,  normally  transformed  into  the  vesico-umbilical  liga- 
ment, may  also  be  found  pervious.  Sometimes  small  openings 
exist  in  the  linea  alba,  through  which  masses  of  fat  protrude 
(hernise  adiposse). 

The  areolar  tissue  between  the  fascia  transversalis  and  the 
peritoneum  is  very  loose  and  elastic,  and  contains  a  varying 
amount  of  fat  in  its  meshes.  Its  fibres  can  easily  be  teased 
apart,  so  as  to  expose  the  underlying  peritoneum  ;  and  if  it  con- 
tains little  fat,  or  if  the  peritoneum  is  adherent  to  an  abdominal 
tumour,  it  may  be  mistaken  for  the  tumour  wall,  and  be  sepa- 
rated from  the  parietes  for  some  distance  before  the  mistake  is 
discovered.  It  may  usually  be  separated  into  two  or  more 
layers. 

The  peritoneum  varies  in  thickness  according  to  idiosj-ncrasy, 
or  as  it  is  thickened  by  inflammation  or  thinned  by  distension. 
When  there  is  much  inflammation,  the  peritoneum  may  be  a 
thick  highly  vascular  tissue,  which  bleeds  freely  on  division ; 
when  the  acuteness  of  the  inflammatory  process  has  subsided,  it 
may  be  united  more  or  less  firmly,  by  organised  bands  of  fibrous 
tissue,  to  the  underlying  tumour;  and  in  this  case  also  its  vascu- 
larity will  be  increased.  Generally  speaking,  an  undue  amount 
of  bleeding  during  division  of  the  parietes  may  be  taken  as  indi- 
cating adhesion  of  peritoneum  to  intra-abdominal  structures. 

The  first  incision  need  not  be  longer  than  two  or  three 
inches,  according  to  the  thickness  of  the  abdominal  walls.  The 
lower  extremity  of  the  wound  is  at  a  distance  of  two  inches  from 
the  pubes.     Lower  than  this  it  is  not  advisable  to  go,  on  account 

10  * 


132  OVARIOTOMY. 

of  the  proximity  of  the  bladder  ;  if  the  opening  is  found  to  be 
too  small,  it  is  enlarged  upwards.  The  amount  of  subcutaneous 
fat  is  estimated  by  touch,  and  the  first  incision  divides  skin  and 
more  or  less  of  the  fatty  layer.  One  or  two  rapid  cuts  along 
the  whole  length  of  the  wound  complete  the  division  of  this  layer, 
and  expose  the  linea  alba.  Bleeding  points  are  caught  up  in 
pressure  forceps.  A  glance  at  the  fibrous  aponeurosis  may,  by 
showing  a  symmetrical  arrangement  of  its  fibres,  indicate  exactly 
the  middle  line.  One  or  two  dexterous  movements  of  the  scalpel 
divide  the  aponeurosis  in  the  middle  of  the  wound.  If  the 
muscle  is  exposed,  a  little  movement  of  the  divided  fibres  over 
it  will  show  on  which  side  of.  the  linea  alba  the  opening  has  been 
made,  and  the  rest  of  the  division  is  completed,  upwards  and 
downwards,  close  to  the  middle  line.  This  exposure  of  muscular 
fibre  is  of  little  practical  moment.  Indeed,  some  operators  prefer 
always  to  expose  muscle,  and  more  than  one  skilled  operator 
recommends  that  the  opening  be  made  through  the  muscular 
fibres.  The  reason  given  is,  that  a  firmer  and  broader  cicatrix 
is  got  from  union  of  muscle  than  from  union  of  fibrous  tissues. 
Whether  this  be  true  or  not,  which  is  more  than  doubtful,  it  is 
certain  that  perfectly  good  union  is  obtained  when  exposed 
muscular  surfaces  are  brought  into  apposition.  The  division  is 
made  by  the  knife  alone,  or  by  scissors ;  no  director  is  required. 
The  loose  transversalis  fascia  is  now  exposed.  If  it  contains 
a  considerable  amount  of  fat,  this  is  pushed  aside,  and  the 
peritoneum  exposed  by  teasing.  The  deeper  fibres  of  this 
fascia  are  usually  divisible  into  several  layers.  These  may  be 
divided  in  various  ways — by  director  and  knife,  by  director  and 
scissors,  by  scissors  alone,  or  by  forceps  and  knife.  As  a  general 
rule,  I  think  the  last  is  the  best  plan.  Where  it  seems  to  be 
feasible,  the  best  plan  of  all  is  to  pinch  up  fascia  and  peritoneum 
between  the  forefinger  and  thumb  ;  roll  it  from  side  to  side  to 
make  certain  that  no  bowel  is  included,  and  open  the  peri- 
toneum by  a  minute  incision,  through  which  the  blade  of  the 
scissors  may  be  inserted  to  complete  the  division.  The  most 
generally  applicable  proceeding  is,  to  catch  up  a  small  portion 
of  fascia  between  pressure  forceps  and  divide  it  between  them. 


EMPTYING    THE  CYST.  133 

pulling  the  peritoneum  outwards ;  if  this  does  not  effect  an 
entrance,  another  little  piece  is  caught  between  two  pairs  of 
forceps,  pulled  outwards  and  divided  till  the  cavity  is  entered. 
The  peritoneum  is  thus  divided  towards  the  outside,  and  all 
risk  of  wounding  intra-abdominal  structures  is  avoided.  The 
completion  of  the  opening  is  made  by  scissors,  protected  by  the 
finger  inside  the  abdomen.  The  forceps  may,  if  so  desired,  be 
left  lying  on  the  abdominal  wall  attached  to  the  edges  of  the 
peritoneum,  keeping  it  everted,  and  preventing  it  from  being 
stripped  in  the  subsequent  manipulations.  For  picking  up  the 
peritoneum,  Spencer  Wells  recommends  the  use  of  Adams's 
double  sharp  hook.  Before  opening  the  peritoneum,  all  bleeding 
must  be  checked  by  forcipressure ;  and,  after  dividing  the  peri- 
toneum, before  proceeding  further,  its  edges  should  be  inspected 
to  see  that  no  haemorrhage  is  going  on. 

The  incision  should  be  long  enough  to  admit  of  the  extraction 
of  the  collapsed  and  empty  cyst  without  using  force  ;  that  is  to 
say,  it  will  range  between  one  and  a  half  or  two  inches  to  eight 
or  ten.  The  size  of  the  tumours  and  the  efficient  treatment  of 
adhesions  alone  should  regulate  the  length  of  incision.  While 
the  chances  of  ventral  hernia  are  diminished  by  a  short  incision, 
the  actual  difficulties  of  the  operation  should  never  be  increased 
by  working  through  a  cramped  opening.  The  rule  to  make  the 
first  incision  long  enough  to  admit  the  hand  should  be  abolished  : 
the  length  of  the  incision  is  to  be  regulated  by  principles  more 
weighty  than  mere  exploration,  which  is  usually  both  meddle- 
some and  unnecessary. 

Emptying  and  Removing  the  Cyst.  Separation  of  Adhesions. — 
Some  idea  of  the  nature  of  the  exposed  tumour  will  have  been 
rapidly  formed  by  sight  and  touch.  The  characteristic  appear- 
ances, already  described,  of  a  cystoma  and  of  a  dermoid  growth  ; 
the  density,  toughness,  or  friability  of  the  cyst-wall;  the  nature 
of  the  contents  as  to  fluidity  or  viscidity  ;  the  multiplicity  of 
secondary  cysts ;  and  the  presence  or  absence  of  adhesions  or 
inflammation,  will  all  be  noted.  A  skilled  surgeon  will  instan- 
taneously decide  as  to  the  best  practical  means  of  dealing  with 


134  OVARIOTOMY. 

each  and  all  of  such  peculiarities  in  the  growth  to  be  removed ; 
here  it  is  possible  to  give  only  general  directions. 

Whatever  be  the  condition,  it  is  always  best  to  begin  by 
emptying  the  cyst.  To  explore  with  the  finger  is,  in  the  great 
majority  of  cases,  to  satisfy  curiosity  rather  than  to  help  in  the 
treatment.  And  to  begin  by  separating  adhesions,  is  a  double 
mistake.  By  so  doing,  not  only  do  we  run  the  risk  of  rupturing 
the  cyst-wall  and  letting  the  contents  of  the  full  cyst  escape 
into  the  peritoneum,  but  we  also  deal  with  the  adhesions  at  the 
most  inopportune  period,  when  there  is  little  room  for  manipula- 
tion, and  a  likelihood  of  leaving  bleeding  points  unsecured 
because  they  may  not  be  seen. 

The  best  mode  of  emptying  the  cyst  is,  in  the  large  majority 
of  cases,  by  tapping.  When  the  growth  is  divided  into  a  great 
number  of  cysts,  or  if  the  cyst-contents  be  very  viscid,  incision 
may  be  the  best  plan. 

For  a  cyst  of  small  size,  the  best  tapping  instrument  is 
Wells's  small  cyst  trocar  (Fig.  21) ;  for  a  large  cyst,  Tait's 
instrument,  with  blunt  conical  point,  may  be  used.  (Fig.  20.) 
Keith  uses  a  very  large  exhausting  aspirator,  and  this  is  probably 
the  best  plan  of  all.  To  prevent  the  escape  of  fluid  by  the  side 
of  the  trocar,  a  sponge  is  all  that  is  requisite.  To  keep  the 
bowels  from  extruding  the  best  plan  is,  not  to  push  the  abdominal 
walls  backward  on  the  cyst,  but  to  pull  the  cyst  forwards  on  the 
edges  of  the  opening.  As  the  cyst  becomes  flaccid,  Wells's 
large  forceps  are  made  to  grasp  the  cyst-wall  and  pull  it  steadily 
but  gently  out  of  the  wound.  A  flat  sponge  placed  between  the 
cyst  and  the  parietes,  may  be  useful  in  preventing  the  escape 
of  fluid  into  the  abdominal  cavity.  Secondary  cysts  may  be 
emptied  without  removing  the  cannula  from  the  main  cyst :  but, 
whilst  this  is  being  done,  the  fingers,  inside  the  abdomen,  should 
make  certain  that  the  trocar  is  not  pushed  through  the  main 
cyst-wall.  As  the  cyst  becomes  flaccid  the  trocar  opening  is 
pulled  over  the  edge  of  the  wound ;  and  as  soon  as  it  is  clear  of 
the  abdominal  opening,  a  fold  of  the  cyst-wall,  above  and 
below,  is  caught  in  strong  forceps,  the  trocar  is  removed,  and 
the  wall  freely  incised  between  the  forceps,  permitting  the  cyst 


SEPARATION  OF  ADHESIONS.  135 

contents  to  run  over  the  macintosh  into  the  receptacle  below. 
Secondary  cysts  are  broken  down  by  two  fingers  inserted  into 
the  incision  in  the  large  cyst,  or,  if  necessary,  by  the  whole  hand. 
Should  bleeding  be  free  during  the  breaking  down  of  the  septa, 
the  incision  must  be  prolonged,  to  permit  of  the  whole  tumour 
being  delivered  so  that  its  pedicle  may  be  compressed.  If 
adhesions  do  not  prevent  it,  the  whole  cyst  is  delivered  as  soon 
as  it  is  sufficiently  diminished  in  bulk ;  if  adhesions  do  exist, 
they  are  divided  as  they  come  into  view,  in  a  manner  to  be 
presently  described. 

When  it  is  deemed  advisable  to  evacuate  the  cyst  contents 
by  incision  (a  few  surgeons  always  adopt  this  method),  two 
large  Wells's  forceps  are  attached  to  the  cyst-wall,  opposite  the 
ends  of  the  wound,  and  an  incision  made  between  them,  while 
they  are  forcibly  pulled  upwards,  so  as  to  keep  the  cyst-wall  in 
contact  with  the  parietes.  Interposed  flat  sponges  gather  up 
any  escaping  fluid.  The  cyst-wall  is  sometimes  so  tense  that  it 
is  not  easy  to  get  a  grip  by  the  forceps ;  in  this  case,  as  much 
as  possible  is  first  pinched  up  by  small  forceps,  and  the  large 
forceps  are  placed  below  the  fold  thus  made.  Dermoid  cysts 
are  in  most  cases  best  emptied  by  incision. 

If,  after  emptying  the  cyst  as  completely  as  possible,  adhe- 
sions prevent  its  being  delivered,  a  large  T-shaped  forceps  is 
placed  on  the  opening,  so  as  to  close  it,  ane  the  important  steps 
of  separating  the  adhesions  are  begun.  For  separating  very 
soft,  fine,  and  recent  adhesions,  nothing  is  better  than  a  sponge. 
The  adherent  organ  is,  so  to  speak,  sponged  away  from  the 
tumour,  and  the  sponge  is  left  overlying  the  adhesions  it  has 
pushed  aside,  so  as  to  absorb  any  blood  that  may  ooze  from  the 
divided  minute  vessels.  Adhesions  of  firmer  consistency  are 
dealt  with  in  various  manners.  If  comparatively  recent,  they 
may  be  carefully  peeled  off  the  tumour  with  the  fingers,  while 
forceps  are  applied  as  often  as  necessary  and  left  attached.  If 
the  adhesions  are  old,  fibrous,  and  thick,  they  are  surrounded 
by  ligatures  and  divided.  Speaking  generally,  soft  adhesions 
which  may  be  sponged  off  are  usually  found  on  the  parietes  or 
the  liver  ;  adhesions  which  may  be  peeled  off  by  the  fingers  are 


136  OVARIOTOMY. 

most  frequently  omental ;  and  division  between  forceps  is  in 
most  cases  required  when  bowel  is  attached  to  the  tumour. 
Attachments  to  uterus  and  bladder,  if  they  exist  at  all,  are 
usually  intimate  and  dense,  and  their  separation  requires  care 
and  judgmeut. 

Wherever  it  is  possible,  forceps  are  brought  out  through  the 
wound  and  left  there  while  the  soft  tissues  are  placed  between 
the  folds  of  a  flat  sponge  or  thick  sponge-cloths.  And,  generally, 
as  the  separation  proceeds,  sponges  are  placed  in  every  gap 
made  between  the  tumour  and  the  detached  organ.  When  the 
whole  tumour  is  delivered,  a  large  sponge  is  placed  over  the 
bowels,  to   protect  them  and  to  prevent  their  escaping. 

During  the  separation  of  adhesions  the  wails  of  any  of  the 
hollow  viscera  may  be  torn.  Such  lacerations  must,  of  course, 
be  immediately  closed  by  suitable  sutures.  If  at  any  point  the 
connection  to  bowel  or  bladder  is  so  intimate  that  complete 
separation  seems  fraught  with  danger  to  the  integrity  of  the 
organ,  then  the  adherent  portion  of  cyst-wall  must  be  cut  off 
and  left  behind.  In  removing  a  very  large  suppurating,  putrid, 
and  universally  adherent  Fallopian  cyst,  I  had  to  leave  behind 
a  considerable  portion  of  the  thick  cyst-wall  in  a  matted  mass 
of  inflammation  sessile  on  the  left  iliac  vessels  and  the  sigmoid 
flexure.  After  drainage  and  daily  syringing  for  more  than  a  month 
this  came  away  through  the  drainage  opening  as  a  slough  which 
filled  a  three-ounce  bottle.  "A  fsecal  fistula  resulted,  which 
spontaneously  healed.  Considerable  portions  of  uninflamed  and 
healthy  cyst-wall  may  be  left  behind  without  incurring  risk. 

For  the  management  of  many  abnormal  conditions  which 
are  constantly  arising  in  bad  cases,  definite  instructions  can 
scarcely  be  given.  Such  instructions  would  be  as  endless  as  the 
complications  ;  they  could  never  be  exhaustive.  If  broad  guiding 
principles  are  fully  mastered,  and  the  surgeon  has  a  fair  know- 
ledge of  the  general  surgery  of  the  abdomen,  he  may  safely  be  left 
to  manage  the  ordinary  complications  met  with  in  ovariotomy. 

Treatment  of  the  Pedicle. — The  pedicle  has  been  subjected  to 
almost  every  conceivable  surgical  treatment.     "  It  has  been  tied 


TREATMENT   OF   THE   PEDICLE.  137 

entire,  tied  in  sections,  been  twisted  off,  burnt  off,  crushed  off, 
cut  square  off,  cut  off  in  flaps,  left  inside,  left  outside,  and  been 
made  to  slough  off."  * 

It  has  always  seemed  to  me  that  this  qncEstio  vexata  of 
ovariotomy  has  been  unduly  magnified  in  importance.  To  a 
surgeon  accustomed  to  deal  with  amputated  limbs  the  pedicle 
is,  comparatively,  a  small  matter.  A  few  small  vessels  to 
supply  a  pound  or  two  of  not  very  vascular  tissue,  with  slight 
fluid-pressure  and  little  foreign  material  around  them,  ought  not 
to  alarm  us.  We  rarely  have  a  vessel  larger  than  the  radial  to 
deal  with,  and  very  rarely  one  that  will  spout  a  stream  to  a 
distance  of  six  inches.  The  cases  are  few  indeed  where  the 
whole  of  the  vessels  may  not  easily  be  compressed  between  the 
fingers.  True,  the  very  facts  that  the  blood-pressure  in  the 
vessels  of  the  pedicle  is  low,  and  that  the  vascular  walls  are 
thin,  are  against  their  capacity  for  self-occlusion  by  the  ordinary 
*   Sutton,  Trans.  Amev.  Gyn.  Soc,  1883,  vol.  vii.,  p.  119. 

From  this  source  is  derived  the  following  instructive  historical  summary  of 
the  treatment  of  the  pedicle  in  ovariotomy  : 

1809.  McDowell  tied  with  single  ligature,  and  left  ends  outside. 

1820.  Chrysmar  of  Wttrtemberg  tied  in  two  portions,  leaving  ends  out. 

1 82 1.  Nathan  Smith  tied  arteries  separately  with  strips  cut  from  kid  glove, 

cut  ligatures  short,  and  dropped  in  pedicle. 
1837.  Stilling  of  Cassel  used  cautery,  and  suggested  stitching  pedicle  in 

wound. 
1846.  Handyside  of  Edinburgh  carried  ligatures  through  Douglas's  pouch 

into  vagina. 

1848.  Stilling  treated  pedicle  outside  peritoneal  cavity. 
1850.  Duffin,  London,  began  Stilling's  plan  in  England. 

1849.  Maissonneuve  of  Paris  twisted  the  entire  pedicle. 

1850.  Atlee  used  the  ecraseur,  and  many  followed  him. 
1850.  Hutchinson  invented  clamp. 

i860.  Sir  James  Simpson,  acupressure  inside  abdominal  wall. 

1865.  Koeberle  invented  his  serre-nceud,  or  wire-constrictor,  with  which 

he  grooved  the  pedicle  prior  to  ligation. 
1864.  Baker  Brown  used  Stilling's  cautery. 
1868.  Masslovsky,  double  flaps,  and  stitched  them. 
i86g.  McLeod  of  Glasgow,  torsion  between  two  pairs  of  strong  forceps. 
1870.  Emmet,  18  cases  treated  with  silver  wire. 

Billroth  catches  pedicle  between  two  forceps,  ligatures,  and  divides 
with  thermo-cautery. 

Nussbaum  ties  pedicle  in  sections  with  catgut  and  drops  in. 


138 


OVARIOTOMY. 


pathological  process  after  deligation.  If  haemostasis  is  easy, 
it  must  be  thorough  and  all-embracing.  But  it  need  not  be 
overdone. 

At  present  we  are  practically  left  to  choose  between  two 
methods  of  securing  the  pedicle,  both  almost  perfect — the 
ligature,  complete  and  intra-peritoneal ;  and  the  clamp  and 
cautery.  It  is  almost  certain  that  extra-peritoneal  treatment 
by  the  clamp  is  now  permanentl)^ 
abolished,  and  I  shall  not  describe  it. 
With  scarcely  an  exception,  there  is 
no  sort  of  pedicle  which  can  be  clamped 
that  may  not  be  tied ;  and  almost  any 
form  of  deligation  is  as  good  as  any 
method  of  clamping. 

In  the  hands  of  Keith,  the  method 
of  cautery  and  clamp  has  reached  per- 
fection as  nearly  as  any  surgical  pro- 
cedure can.  The  minute  accuracy  of 
his  manipulation,  leaving  a  thin,  grey, 
translucent  band  of  anaemic  but  still 
living  tissue,  few  surgeons  can  hope  to 
equal,  and  certainly  none  to  excel;  and, 
in  the  face  of  the  undoubted  safety  of 
the  more  easy  and  rapid  ligation,  I 
doubt  if  many  surgeons  will  seek  to 
imitate  him. 

The  clamp  which  Keith  uses  is 
essentially  that  introduced  by  Baker 
Brown  in  1864.  (Fig.  23.)  Two  flat 
steel     bars,     each     provided     with    a 

powerful  handle,  are  joined  at  their  distal  ends  by  a  strong 
hinge ;  on  their  under  surface  are  two  thick  ivory  plates, 
which  extend  a  little  way  beyond  the  metal  and  act  as  non- 
conductors. On  the  left  blade  is  fitted  an  upright  guard, 
against  which  the  cautery  may  be  pressed,  so  as  to  prevent 
slipping.     The  cautery  irons  are  very  large,  so  that  they  retain 


Fig.  23. 

Keith's  Cautery  Clamp. 
One-third  size. 


CAUTERY  AND   CLAMP. 


139 


their  heat  for  a  long  time,  and  they  are  variously  shaped 
(Figs.  24  &  25)  to  suit  the  nature  of  the  work.  A  hatchet-shaped 
cautery  may  be  used  for  cutting  through  the  pedicle,  pressing 
it  into  the  angle  formed  between  the  guard  and  the  clamp. 
Disc-shaped  cauteries  are  used  for  smooth- 
ing down  and  finally  coagulating  the  seared 
edge.  The  cauteries,  of  which  there  should 
be  two  or  three  at  hand  and  ready  for  use, 
are  heated  in  an  ordinary  coal  fire. 

In  using  the  cautery-clamp,  the  ped- 
icle is  laid  out  at  a  convenient  distance 
from  the  tumour  between  the  blades. 
The  tissues  in  the  pedicle  are  left  un- 
disturbed as  far  as  possible  ;  compression 
is  put  upon  them  in  the  position  which 
they  naturally  assume,  and  there  is  thus 
no  tendency  for  the  pedicle  to  untwist. 
The  blades  are  tightened  up  by  the  screw 
as  firmly  as  possible.  Then  the  tumour 
is  cut  off"  with  scissors  about  half  an  inch 
from  the  clamp.  Before  applying  the 
cautery  to  the  pedicle,  wet  cloths  are  laid 
around  the  clamp  under  the  ivory,  so  as 
to  prevent  over -heating  of  the  neigh- 
bouring tissues. 

The  cauteries  used  must  be  as  hot  as 
possible.     They  are  rubbed  up  and  down 
the  blades  of  the   clamp   against  the  up- 
right   guard,  till  the  line  of   compressed 
pedicle  lying  between  the  steel  blades  is 
perfectly  smooth  and  level.    No  black 
charred  tissue  is  left  behind  to  slough  ; 
when  efficiently  dealt  with,  the  stump 
terminates  in  a  thin  grey  margin  of  dry 
semi-translucent  tissue,  not  unlike  cartilage  in  appearance  and 
consistence.    The  clamp  is  removed  with  circumspection,  catch 
forceps  being  placed  at  each  side  of  the  pedicle,  to  prevent  its 


Fig.  24.       Fig.  25. 

Cautery  Irons  for  Searing  the 
Pedicle.     One-third  size. 


I-IO  OVARIOTOMY. 

slipping  into  the  abdomen.  Sometimes  a  seared  vessel  sticks  to 
the  blades  of  the  clamp,  and  may  be  torn  through  if  the  blades 
are  roughly  removed. 

The  silk  ligatiive  is  now  almost  universally  used  for  securing 
the  pedicle.  There  is  no  objection  to  catgut,  beyond  the  extra 
trouble  necessary  in  preparing  it ;  I  have  used  it  successfully  in 
more  than  twenty  cases,  but  have  now  given  it  up  for  silk. 
And,  as  far  as  written  records  may  be  trusted,  no  special  virtue 
resides  in  any  form  of  silk,  provided  it  be  strong  and  pure. 
Chinese  twist,  of  thickness  varying  according  to  the  size  and 
vascularity  of  the  pedicle,  is  most  generally  used.     It  is  first 

scalded  in  boiling  water,  and  then 
soaked  in  antiseptic  lotion.  There 
are  many  methods  of  tying  the  liga- 
ture ;  no  method,  in  my  opinion,  is 
superior    to    Lawson   Tait's    Stafford- 

FiG.  26.  ^^^^^  ^"°^-     (^^^-  ^^-^ 

"  An  ordinary  handled  needle,  armed 
Tait's  Staffordshire  Knot.  ^^it^  a  long  piece  of  the  silk  required, 
is  passed  through  the  pedicle  and  then 
withdrawn,  so  as  to  leave  a  loop  on  the  distal  side.  This  loop 
is  then  drawn  over  the  ovary  or  tumour,  and  one  of  the  free  ends 
drawn  through  it,  so  that  one  end  is  above,  while  the  other  is 
under,  the  retracted  loop.  Both  ends  being  seized  in  the  hand, 
they  are  drawn  through  the  pedicle,  against  which  the  thumb 
and  forefinger  of  the  left  hand  are  pressed,  as  a  fulcrum,  till 
complete  constriction  is  made.  A  simple  hitch  is  then  made, 
as  in  the  drawing,  and  tightened ;  and  that  is  followed  by 
another,  as  in  ordinary  ligature-tying.  There  is  another  and 
more  complicated  way  of  making  the  knot,  by  passing  each  end 
of  the  thread  round  the  corresponding  half  of  the  pedicle,  and 
crossing  them  within  the  loop  in  front,  which  is  equally  effective, 
and  which  may  be  used  in  cases  of  large  solid  tumours.  But 
the  former  is  by  far  the  more  elegant  and  rapid  method." 

The  advantages  which  Tait  justly  claims  for  his  knot  are, 
that  "  while  it  ties  the  pedicle  in  two  halves,  these  halves  are 


LIGATING    THE   PEDICLE. 


141 


Fig.  27. 

Triple  Interlocking  Ligature, 
threads  inserted. 


The 


compressed  really  into  one  surface ;  the  two  halves  are  equally- 
well  compressed  ;  and  from  the  mechanical  arrangement  of  the 
knot,  very  great  constricting  force  can  be  employed." 

The  Staffordshire  knot  is,  as 
every  ligature  applied  to  the 
pedicle  should  be,  an  interlock- 
ing one.  Ligatures  should  never 
be  applied  to  the  pedicle  in  sec- 
tions so  as  to  split  it.  Such 
splitting  extends  downwards 
some  way  below  the  site  of  deli- 
gation,  and  may  pass  through  a 
thin  -  walled  vessel  which  may 
bleed  very  freely.  In  some 
cases  of  thick  or  broad  ped- 
icle, double  deligation  by  the 
Staffordshire  knot  may  not  seem 
sufficient ;  then  ligation  in  three 
or  four  portions  may  be  ad- 
visable. In  such  a  case  the 
threads  must  be  interlocked  so 
that  the  pedicle,  while  it  is  tied 
in  sections,  is  still  compressed 
as  a  whole  towards  its  centre, 
and  splitting  is  thus  rendered 
impossible.  The  accompanying 
diagrams  (Figs.  27,  28,  29)  show 
how  this  may  easily  and  rapidly 
be  done,  when  we  desire  to  make 
deligation  in  three  portions.  A 
piece  of  silk  long  enough  to 
form  three  ligatures  is  threaded 
in  the  blunt  pedicle  needle.  The 
needle  is  passed,  at  about  a  distance  of  one-third  of  the 
breadth  of  the  pedicle  from  one  of  its  margins,  through  an 
area  in  which  there  are  no  vessels,  or  from  which  the  vessels 
have   been   pushed  aside ;   the   silk   is   caught   in   a  loop    over 


Triple  Interlocking  Ligature.     The 

threads  interlocked  ready 

for  tying. 


Fig.  29. 

Triple  Interlocking  Ligature  Tied. 


142  OVARIOTOMY. 

a  finger  of  the  left  hand,  and  the  needle  withdrawn  still 
threaded.  It  is  re-inserted  midway  between  the  point  of  inser- 
tion and  the  other  margin,  the  loop  is  caught  up  on  another 
finger,  the  needle  is  withdrawn  unthreaded  and  laid  aside.  The 
pedicle  is  now  transfixed  by  a  continuous  ligature,  which  has 
two  loops  showing  on  one  side,  and  one  loop  and  two  free  ends 
on  the  other  side.  (Fig.  27.)  The  two  free  ends  are  now  passed 
under-  the  loop  lying  on  their  own  side.  (Fig.  28.)  The  two 
loops  on  the  other  side,  still  held  on  the  fingers,  are  now  divided 
by  scissors,  and  the  ends  of  the  middle  ligatures  surrounding 
the  middle  of  the  pedicle,  and  including  the  ligatures  which 
surround  the  two  sides  of  the  pedicle,  are  tied  as  tightly  as 
possible.  The  lateral  ligatures  are  then  tied  one  after  the  other. 
Thus  a  complete  interlocking  ligature  holds  the  pedicle.  (Fig. 
29.)  The  same  process  may  be  carried  out  with  four  or  five, 
or  indeed  any  number  of  ligatures. 

It  is  always  wise  to  use  a  blunt  needle  for  transfixing  the 
pedicle,  as  there  is  often  some  risk  of  wounding  vessels.  I  use 
an  aneurism  needle  for  this  purpose.  A  finely-pointed  forceps, 
like  a  Lister's  sinus  forceps,  is  an  excellent  instrument  for  this 
purpose ;  the  thread  is  caught  between  the  blades  and  pulled 
backwards  through  the  opening.  If  the  pedicle  is  very  bulky, 
it  may  be  advisable  to  squeeze  it  in  a  temporary  clamp,  or 
between  the  blades  of  powerful  compressing  forceps  at  the  site 
of  deligation,  before  tying  the  thread.  Bantock  in  particular 
uses  this  method,  employing  two  powerful  Wells's  forceps,  bent 
at  an  angle,  for  the  purpose.  The  needle  transfixes  the  ped- 
icle near  the  tips  of  the  blades,  and  the  ligatures  are  tightened 
while  the  forceps  are  being  removed.  Such  compression  drives 
the  fluid  out  of  the  tissues  at  the  point  where  the  ligature  lies,  and 
prevents  their  slipping  away  from  under  the  encircling  thread. 
In  thick  oedematous  pedicles  this  plan  is  valuable,  and  should 
be  always  adopted ;  for  ordinary  pedicles,  experience  has  abun- 
dantly shown  that  it  is  at  least  not  essential.  It  is  possible  to 
overdo  crushing  of  the  pedicle  ;  there  is  undoubtedly  some 
theoretical  force  in  the  reasoning  of  Thornton  and  Doran,  that 
over- compression  is  likely  to  lead    to   sloughing.      But,   as  a 


CLEANSING   THE  CAVITY.  143 

matter  of  fact,  it  would  appear  that  no  positive  harm  arises 
from  the  almost  universal  practice  of  pulling  the  ligatures  as 
tightly  as  possible.  It  will  always  be  found  that  in  fleshy  or 
cedematous  pedicles  the  ligature  may  be  drawn  more  tightly 
after  the  tumour  is  cut  away.  While  the  first  hitch  is  being 
drawn  tight  the  pedicle  is  cut  through  about  half  an  inch 
above  the  ligature  by  successive  snips  of  the  scissors  cutting 
from  periphery  to  centre ;  the  tissues  at  once  become  softer,  and 
the  thread  may  be  drawn  in  more  tightly.  But  this  is  rarely 
necessary.  With  Tait's  knot,  very  ordinary  force  will  be  amply 
sufficient  to  render  hasmostasis  complete  and  permanent. 

Experienced  operators  use  other  modes  of  securing  the 
pedicle  by  ligature.  But  for  simplicity  and  efficiency,  no 
methods  are  superior  to  those  described. 

A  single  thickness  of  silk,  placed  by  transfixion  as  described, 
and  secured  by  a  true  reef-knot,  will  suffice  for  the  great 
majority  of  pedicles.  Extra  ligatures,  to  provide  against  the 
chance  of  haemorrhage,  import  a  new  danger  in  the  risk  of 
their  not  becoming  absorbed  or  encapsuled.  The  thinnest  silk 
compatible  with  safety,  the  smallest  knot,  and  the  least  possible 
handling  of  the  pedicle,  is  the  most  perfect  surgery. 

The  pedicle,  secured  and  divided,  is  dropped  into  the  cavity 
and,  in  most  cases,  need  not  be  again  looked  at.  If  there  is  any 
doubt  as  to  its  being  properly  secured,  a  catch  forceps  may  be 
attached  to  the  stump,  whereby  it  may  be  drawn  to  the  surface 
and  inspected  before  finally  closing  the  wound.  The  sponges, 
however,  which  are  subsequently  carried  into  Douglas's  pouch 
will  scarcely  fail  to  show  if  there  is  bleeding  from  the  pedicle. 
At  this  stage  the  alternate  ovary  should  be  inspected.  If  it  is 
diseased,  it  should  be  removed. 

Cleansing  the  Peritoneal  Cavity. — One  of  the  most  important 
steps  in  the  operation  is  the  complete  removal  of  all  foreign 
material  from  the  cavity — the  "toilet  of  the  peritoneum,"  as 
it  has  well  been  called.  Mc  Dowell  himself  partially  anti- 
cipated this  proceeding ;  but  to  Keith  we  are  indebted  for 
fully  demonstrating  its  extreme  value.      The  modes  of  carr3ing 


144  OVARIOTOMY. 

out  this  proceeding  are  the  same  for  all  abdominal  operations, 
and  need  not  again  be  fully  described.  With  a  suitable 
sponge-holding  forceps,  sponges  are  successively  carried  into 
Douglas's  pouch  and  into  the  hollows  of  the  loins  ;  and  they 
are  re-introduced  till  they  return  dry.  If  glutinous  or  semi- 
solid foreign  matter  is  present,  Tait's  excellent  plan  of  washing 
out  the  abdomen  b}^  warm  fluid  should  be  adopted.  If  there  is 
no  special  apparatus,  the  rubber  tubing  of  the  trocar,  to  act  as 
an  irrigating  tube,  and  a  basin  or  ewer  to  hold  two  or  three 
quarts  of  fluid,  will  suffice.  The  wound  is  kept  as  close  as 
possible  with  one  hand,  while  the  fingers  of  the  other  are 
moved  about  among  the  intestines,  washing  and  cleansing  them 
thoroughly.  The  process  is  continued  till  the  fluid  returns 
clear.  Dry  sponges  are  then  placed  in  the  pelvis  and  in  the 
loins,  to  be  removed  after  the  sutures  have  been  inserted,  but 
before  they  have  been  tied.  In  many  cases  the  fluid  may  be 
poured  in  from  a  jug. 

It  is  impossible  to  insist  too  strongly  on  the  importance  of 
removing  all  foreign  matter  from  the  peritoneal  cavity.  But 
a  judicious  balance  between  efficiency  and  excess  must  be 
observed  here,  as  well  as  everywhere  else.  Too  much  sponging 
may  irritate  the  peritoneum  ;  one  may  go  on  for  a  considerable 
period  squeezing  out  a  few  drops  of  fluid  from  the  sponges, 
which  contain  nothing  more  than  peritoneal  secretion  thrown 
out  from  irritation.  And  if  the  patient  is  seriously  collapsed 
from  a  prolonged  operation,  it  may  be  wise,  in  balancing  possi- 
ble evils,  to  curtail  the  cleansing  of  the  peritoneum,  and  either 
run  the  subsequent  risks  or  drain. 

Drainage. — The  question  of  drainage  is  a  very  difficult  one  to 
speak  about  in  theory.  In  practice,  a  good  rule  to  follow  is, 
"  When  in  doubt,  drain."  If  little  or  no  fluid  comes  away 
through  the  tube,  it  may  be  removed  in  twenty-four  hours,  and 
no  harm  is  done.  If  fluid  does  come  away,  we  have  the  satis- 
faction of  seeing  that  a  danger  has  been  avoided.  Fewer  cases 
have  died  from  drainage  than  from  the  want  of  it. 

In  cases  with  deep  pelvic  adhesions,  the  bleeding  from  which 


DRESSING   THE    WOUND.  145 

it  may  be  impossible  to  see  or  effectually  to  control,  drainage 
is  specially  indicated.  Where  a  raw  surface  has  been  left  be- 
hind— on  bladder,  pelvis,  or  parietes — we  may  expect  subsequent 
sero-sanguinolent  oozing,  and  we  drain  if  we  expect  the  amount 
to  be  considerable.  In  any  case  where  putrid  fluid  had  escaped 
into  the  cavity  we  should  be  careful  to  drain.  If,  generally,  we 
apprehend  an  excessive  secretion  of  fluid,  or  if  we  are  in  doubt 
as  to  the  peritoneum  being  thoroughly  cleansed,  drainage  ought 
to  be  adopted. 

Keith's  glass  tubes  are  the  best  for  use  after  ovariotomy. 
The  tube  must  not  be  too  long  or  too  short.  The  end  of  it 
should  touch  the  bottom  of  Douglas's  pouch,  without  pressing 
upon  the  rectum  ;  while  the  collar  rests  upon  the  edges  of  the 
wound,  at  its  lower  extremity.  Pressure  must  not  be  put  on  the 
tube  by  dresser  or  binder.  The  end  of  it  is  passed  through  a 
button-hole  opening  in  a  sheet  of  rubber ;  over  the  end  is 
placed  an  absorbent  dressing ;  and  in  the  tube  is  placed  a 
twisted  roll  of  gauze,  to  exhaust  fluid  by  capillary  action.  If 
capillary  action  and  intra-abdominal  pressure  do  not  remove  the 
fluid  from  the  abdomen,  then  a  suction  apparatus,  such  as  Tait's 
(Fig.  14),  must  be  used  at  frequent  intervals. 

Suturing  the  Wound.  Dressing. — Little  need  be  added  to  the 
general  remarks  already  made  on  these  points.  At  the  lower 
extremity  of  the  wound,  the  first  suture  is  placed  very  carefully, 
so  as  to  close  completely  the  opened  connective  tissue  spaces, 
and  the  peritoneum  is  here  brought  together  with  special 
accuracy.  The  needle  is  inserted  about  two  lines  from  the 
edge  of  the  wound,  and  carried  straight  through  all  the  layers  in 
the  parietes;  the  peritoneum  usually  requires  adjustment,  so 
that  it  is  pierced  in  a  corresponding  position.  When  the  sutures 
have  been  inserted,  and  the  underlying  sponge  removed,  the 
wound  is  finally  sponged  free  of  all  blood,  while  it  is  pulled 
outwards  by  the  sutures  gathered  together  in  the  hand.  The 
sutures  are  accurately  tied  and  their  ends  cut  off. 

For  dressing,  carbolized  gauze  or  boracic  lint  cut  into  squares 
and  secured  by  strapping  is  as  good  as  any.     As  we  expect  very 

11 


146  OVARIOTOMY. 

little  discharge  from  the  wound,  and  no  subsequent  dressing  is 
required,  the  full  Listerian  dressing  with  macintosh  and  gauze 
bandages  in  unnecessary.  The  advantages  claimed  for  strapping 
over  the  whole  lower  abdomen,  fixing  its  walls  as  in  a  splint, 
and  preventing  passive  gaseous  distension,  need  not  be  re- 
capitulated. I  have  practically  given  up  the  binder,  as  I  believe 
it  causes  more  annoyance,  from  getting  into  folds  under  the 
patient's  back,  than  the  little  good  it  does  is  worth.  Putting  on 
the  binder,  as  the  completion  of  every  form  of  surgical  inter- 
ference with  the  abdomen,  is  a  time-honoured  observance ;  it  is 
difficult  to  say  how  much  more  it  is. 


ACCIDENTS    DURING    THE    OPERATION. 

Mishaps  may  occur  during  the  most  simple  ovariotomies ; 
they  are  especially  frequent  in  difficult  cases.  It  behoves  the 
surgeon  to  be  able,  promptly  and  efficiently,  to  deal  with  these  ; 
for  such  accidents,  unattended  to,  may  involve  consequences 
far  more  serious  than  the  operation  itself. 

Vomiting  and  retching  during  operation  is  a  disagreeable 
complication.  The  straining,  which  is  sometimes  quite  violent, 
tends  to  force  the  intestines  out  of  the  wound.  While  the  cyst 
is  being  emptied,  merely  dragging  it  forwards,  so  as  to  keep 
it  in  close  contact  with  the  abdominal  wall,  will  probably 
suffice  to  keep  back  the  bowels.  As  the  cyst  collapses,  its 
place  may  be  taken  by  large  sponges  packed  around  the  ab- 
dominal opening.  Sometimes  it  will  be  necessary  to  cease 
operating,  and  temporarily  to  close  the  wound  by  hooking 
the  forefinger  under  the  upper  extremity  of  the  abdominal 
opening  and  squeezing  the  walls  together  between  the  thumb 
and  fingers.  The  force  of  the  contracting  abdominal  muscles 
is  sometimes  enormous,  and  requires  considerable  exertion  to 
oppose  it. 

Stripping  the  Parietal  Peritoneum  is  an  accident  likely  to  occur 
only  with  inexperienced  operators.  In  thin  subjects  the  peri- 
toneum may  be  peculiarly  well  defined,  while  it  is  loosely 
attached  to  the  abdominal    wall;    and  if,  in  addition  to  these 


INJURIES    TO    VISCERA.  147 

peculiarities,  it  is  adherent  to  the  underlying  cyst,  it  may  be 
peeled  off  the  parietes  to  a  considerable  extent  before  the  error 
is  discovered.  In  such  a  case  it  is  better  to  cut  the  peeled 
flap  clean  away,  than  to  leave  it  to  run  the  risk  of  becoming 
gangrenous. 

Tearing  of  the  Cyst-wall  and  escape  of  the  cyst-contents  into 
the  cavity  is  not  a  serious  accident,  unless  the  contents  are 
putrid.  A  large  tear  at  the  site  of  puncture  is  best  managed  by 
grasping  the  edges  of  it  with  forceps  and  pulling  the  opening 
out  of  the  wound.  A  laceration  elsewhere  is  either  closed  by 
forceps,  or,  if  large,  is  surrounded  by  flat  sponges.  Bleeding 
from  such  tears  is  sometimes  profuse,  and  must  be  treated  by 
immediately  delivering  the  tumour  and  securing  its  pedicle. 

Injuries  to  the  Hollow  Viscera  are  likely  to  occur  only  when 
there  are  dense,  strong  adhesions  between  them  and  the  cyst- 
wall.  The  walls  of  any  part  of  the  intestine  may  be  torn  through  ;; 
such  a  tear  must  be  stitched  up  before  doing  anything  else^ 
Removal  of  a  considerable  portion  of  mesentery,  incurring  a  risk 
of  gangrene  of  the  intestine,  raises  the  question  of  resection, 
I  have  had  to  remove  the  vermiform  appendix,  for  injuries  done 
to  it  during  operation.  Rupture  of  the  bladder,  if  properly  treated 
by  accurate  suturing,  is  not  so  dangerous  an  accident  as  might 
be  supposed.  I  have  wounded  the  bladder  somewhat  exten- 
sively on  two  occasions,  once  followed  by  free  escape  of  urine  ;: 
in  neither  case  did  any  harm  result.  If  the  gall-bladder  is 
ruptured,  we  may,  according  to  the  extent  of  the  injury,  either 
remove  the  whole  viscus  or  establish  a  fistula  ;  to  stitch  up  the 
laceration  is  not  always  safe.  Rupture  or  division  of  the  ureter 
is  a  serious  accident.  The  ureter  has  been  included  in  a  ligature 
more  than  once.  Only  once  (Nussbaum's  case)  after  such  injury 
to  the  ureter  has  permeability  been  restored  ;  if  the  patient  does- 
not  die,  a  fistula  remains,  which  can  be  cured  only  after  removal 
of  the  kidney.  If  the  patient  is  fairly  strong  and  the  ovari- 
otomy is  not  a  severe  operation,  perhaps  the  best  treatment  of 
complete  division  of  the  ureter  is  to  remove  the  kidney.  If 
suturing  the  division  is  out  of  the  question,  and  it  does  not  seem 
wise  to  attempt  nephrectomy,  the  next  best  plan  is  probably  to- 

11  * 


148  OVARIOTOMY. 

bring  the  end  of  the  ureter  out  of  the  wound,  and  wait  for  the 
recovery  of  the  patient  before  taking  any  further  steps.  Simon's 
first  nephrectomy  was  performed  for  a  fistula  of  the  ureter  made 
during  an  ovariotomy. 

Injuries  to  the  Solid  Viscera — Hver,  spleen,  or  kidney — are  not 
common.  If  bleeding  continues  after  sponge-packing,  the  raw 
surface  must  be  mopped  with  iodine  or  perchloride  of  iron 
solution.  A  serious  injury  to  the  kidney  involves  risk  of  urinary 
extravasation,  and  the  best  treatment  may  be  nephrectomy. 

Foreign  Bodies — instruments  or  sponges — may  be  left  in  the 
adbominal  cavity.  The  best  preventive  is  the  use  of  a  definite 
number  of  each  sort  of  material,  and  counting  after  operation. 
The  counting  of  the  instruments  would  seem  to  be  a  simple 
enough  proceeding ;  yet  it  is  a  fact  that  no  one  but  the  operator 
himself  can  be  made  to  recognise  the  vital  importance  of  being 
absolutely  exact  in  this  duty.  Time  after  time  have  skilled 
assistants  and  nurses  been  found  at  fault ;  and  this  petty  dutj^ 
like  every  other  one,  is  almost  forced  upon  the  operator.  It  is  a 
good  plan  to  make  the  assistant  count  the  items  aloud  in  the 
hearing  of  the  operator ;  and  if  the  surgeon  has  secretly 
abstracted  one  or  other  of  the  instruments,  it  will  add  to  the 
security.  A  foreign  body  must  of  course  be  removed  as  soon  as 
it  is  certain  that  it  is  left  behind. 


ENCAPSULED    OVARIAN    CYSTS. 

Doran  has  given  this  name  to  ovarian  cysts  which  grow 
between  the  layers  of  the  broad  ligament  and  carry  it,  along 
with  the  pelvic  peritoneum,  upwards  into  the  abdominal  cavity. 
The  capsule  on  exposure  is  of  a  pale  red  colour,  contrasting  with 
the  glistening  white  appearance  of  the  underlying  cyst-wall. 

The  cyst  is  tapped  and  delivered  in  the  ordinary  way. 
Should  the  capsule  completely  envelop  the  cyst,  and  show  a 
marked  constriction  between  the  uterus  and  the  tumour,  the 
whole  of  it  may  be  removed  with  the  tumour,  and  the  constriction 
treated  as  an  ordinary  pedicle.  More  commonly,  however,  the 
tumour  is  not  completely  encapsuled  ;  it  has  burrowed  down- 


TREATMENT  AFTER   OVARIOTOMY.  149 

wards  into  the  pelvic  fascia,  and  the  broad  ligament  and  pelvic 
peritoneum  may  be  but  slightly  disturbed  from  their  connection 
with  important  organs.  Then  the  tumour  must  be  shelled  out 
from  the  capsule ;  and  the  capsule  must,  in  whole  or  in  part, 
be  left  behind.  Whilst  the  collapsed  cyst  is  being  dragged  up- 
wards by  the  assistant,  the  operator  peels  off  the  capsule  by 
sponging  and  tearing,  placing  forceps  on  bleeding  points,  till  the 
true  pedicle,  which  is  represented  by  a  few  large  vessels  at  the 
bottom  of  the  tumour,  is  reached.  The  vessels  are  tied  and  the 
tumour  is  cut  away. 

The  empty  capsule,  if  it  can  be  drawn  together  at  the  base, 
and  has  no  important  outlying  connections,  may  be  cut  com- 
pletely away  after  deligation.  If  it  lies  very  deep,  or  has  a 
broad  base,  or  is  intimately  connected  with  important  structures, 
it  may  be  necessary  to  leave  the  whole  or  a  portion  of  it  behind. 
If  the  cavity  left  after  removing  a  portion  of  the  sac  is  small, 
and  there  is  no  oozing,  the  edges  may  be  drawn  together  by  a 
continuous  suture  and  the  abdominal  cavity  closed  over  it. 
Usually,  however,  there  is  some  oozing,  and  then  it  is  wise  to 
stitch  the  edges  of  the  capsule,  gathered  together  by  a  purse- 
string  suture,  to  the  bottom  of  the  parietal  wound  and  insert 
a  drainage  tube. 


TREATMENT   AFTER    OVARIOTOMY. 

One  of  the  first  lessons  that  experience  teaches  in  ova- 
riotomy is  the  futility  of  all  fussy  regulations  as  to  feeding, 
medicines,  catheterism,  posture,  and  such  like.  It  is  wise, 
for  the  first  twenty-four  hours,  to  give  nothing  but  small 
quantities  of  hot  water,  or  hot  toast-water.  In  the  next 
twenty-four  hours,  a  little  oatmeal  gruel,  or  Brand's  essence 
of  meat,  or  similar  preparation,  may  be  given  with  the 
water.  Thereafter,  if  the  case  is  doing  well,  the  patient  may 
have  almost  what  she  asks  for.  Milk  as  food  is  to  be  avoided ; 
sucking  ice  for  thirst  usually  results  in  accumulation  of  fluid  in 
the  stomach,  which  is  rejected.  Thirst  is  usually  considerable 
after  these  operations  :  the  best  way  to  allay  it  is  to  administer 


150  OVARIOTOMY. 

a  pint  of  tepid  water  by  the  rectum.  Often,  after  such  an  enema, 
not  only  is  the  thirst  reHeved,  but  the  patient  breaks  into  a 
gentle  perspiration  and  falls  off  into  a  refreshing  sleep.  The  best 
foods,  from  the  third  day  to  the  fifth  or  sixth,  are :  arrowroot, 
sago,  oatmeal-gruel,  ordinary  beef-tea,  and  such  like.  A  cup  of 
tea  with  thin  bread  and  butter  is  often  much  appreciated.  At 
the  end  of  a  week  the  patient  may  have  ordinary  diet. 

All  medicines  are,  if  possible,  to  be  avoided,  particularly 
opium.  Pain  I  believe  to  be  not  so  strong  an  indication  for 
opium  as  restlessness.  Sickness  and  tympanites  are  predisposed 
to,  if  not  often  caused  by,  opium.  One  expects,  after  the  first 
dose  has  been  administered,  to  see  the  patient  wake  up  in  the 
morning  with  a  dry  tongue,  increased  thirst,  and  some  feeling  of 
nausea,  which  during  the  day  do  not  pass  off,  but  culminate  in 
restlessness  at  night,  requiring  the  administration  of  a  second 
dose.  We  rarely  see  a  case  treated  throughout  with  a  perfectly 
flat  or  retracted  abdomen  if  opium  has  been  administered.  When 
the  patient  tosses  about  in  bed,  fidgety  and  restless,  without 
any  particular  symptoms  beyond  those  incident  to  a  serious 
operation,  opium  is  undoubtedly  of  great  value.  Many  surgeons 
administer  the  opium  by  the  rectum,  and  leave  its  adminis- 
tration to  the  discretion  of  the  nurse :  I  believe  that  a 
hypodermic  injection  of  morphia,  administered  by  the  surgeon 
himself,  is  a  more  satisfactory  and  efficient  method. 

Of  other  medicines,  all  that  need  to  be  kept  in  readiness  are, 
a  saline  purge — a  Seidlitz  powder  is  as  good  as  any — and  tur- 
pentine for  giving  in  enemas.  Of  all  the  effects  of  therapeutics, 
none  is  perhaps  more  striking  than  that  following  the  exhibition 
of  a  saline  purge,  supplemented,  if  necessary,  by  a  turpentine 
enema,  in  abdominal  distension,  on  the  third  or  fourth  day  after 
ovariotomy.  Such  distension  is  usually  taken  as  indicating 
peritonitis,  and  so,  no  doubt,  it  frequently  is ;  but  this  is  no 
contra-indication — rather  the  reverse.  For  moderate  degrees  of 
flatulence,  wearing  the  rectum-tube  is  usually  quite  sufficient ; 
in  greater  amount,  the  flatus  may  be  removed  by  a  hot-water 
enema,  with  or  without  turpentine;  when  the  abdominal  walls  be- 
gin to  become  brawny,  these  means  ought  to  be  supplemented  by 


TREATMENT  AFTER   OVARIOTOMY.  151 

a  purge.  Opium,  except  in  the  special  circumstances  mentioned 
and  in  others  to  be  noted,  is  in  such  conditions  to  be  avoided. 

The  urine  need  not  be  drawn  off  till  the  patient  asks  to  be 
relieved,  and  this  may  not  be  for  twelve  hours  or  even  longer. 
The  secretion  of  urine,  in  these  cases,  is  at  first  scanty;  from 
fifteen  to  twenty  ounces  in  the  first  twenty-four  hours  is  about 
the  average  amount.  The  full  amoimt  is  not  usually  secreted 
till  five  or  six  days  have  passed.  Catheterism  twice  on  the  first 
day,  and  three  times  on  the  second,  will  usually  be  all  that  is 
required  ;  thereafter  the  patient  will  probably  be  able  to  pass 
water  herself.  To  ensure  absolute  cleanliness  of  the  catheter, 
and  avoid  the  risks  of  vesical  catarrh,  it  is  wise  to  give  the 
nurse  a  new  instrument  when  the  one  in  use  has  been  passed 
six  times. 

From  the  beginning  the  patient  may  be  permitted  to  lie  in 
whatever  position  is  most  comfortable,  the  nurse  moving  her. 
If  the  abdomen  is  supported  by  strapping,  this  change  of  posi- 
tion involves  no  risk.  I  have  often  seen  a  patient,  wakeful  in 
the  supine  position,  drop  off  to  sleep  at  once  when  turned  on 
the  side.  Raising  the  limbs  on  pillows,  elevating  the  head  and 
shoulders,  and  numerous  little  attentions  of  this  sort,  which  an 
intelligent  and  conscientious  nurse  will  observe,  all  add  to  the 
patient's  comfort.  The  advantages  of  two  beds,  one  for  the  day 
and  one  for  the  night,  are  self-evident. 

The  condition  of  the  wound  may  be  absolutely  ignored  till 
the  seventh  or  eighth  da}^,  when,  for  the  first  time,  the  dressings 
are  removed  and  the  stitches  taken  out.  Almost  without  excep- 
tion the  wound  will  be  found  perfectly  healed.  Stitch-abscesses 
ought  never  to  occur.  They  are  caused  either  by  filthy  sutures, 
or  by  tying  them  too  tightly.  When  the  stitches  have  been 
removed,  a  piece  of  dry  boracic  lint  or  absorbent  wool  is  placed 
on  the  wound,  and  the  abdomen  is  strapped  up  again.  It  is 
wise  not  to  let  the  patient  get  up  within  the  fortnight,  however 
much  she  may  desire  it. 

Such  is  the  ordinary  treatment  of  a  simple,  straightforward 
case  of  ovariotomy ;   and  the  large  majority  of  cases  proceed 


152  OVARIOTOMY. 

in  this  satisfactory  manner.  In  skilled  hands,  the  average  case 
goes  on,  almost  as  a  matter  of  course,  in  an  uneventful  manner; 
only  difficult  and  severe  cases  are  expected  to  be  followed  by 
serious  illness.  We  often  see  cases  recorded  as  severe  which 
recover  "without  a  bad  symptom."  Every  genuinely  severe 
operation  must  be  followed  by  grave  symptoms ;  and  it  is  in  the 
saving  of  such  cases  after  operation,  almost  as  much  as  by  skill 
in  the  operation  itself,  that  the  greatest  triumphs  in  abdominal 
surgery  are  secured. 

The  first  danger  to  be  surmounted  is  shock  and  collapse. 
This  is  combated  on  ordinary  principles  by  hot-water  bottles, 
warm  blankets,  elevating  the  limbs,  stimulating  enemas,  and,  if 
necessary,  by  hypodermic  injections  of  ether  or  brandy.  In  such 
cases  feeding  by  the  mouth  is  out  of  the  question.  In  every  bad 
case  rectal  feeding  and  stimulation  should  be  begun  almost  from 
the  moment  the  operation  is  concluded.  Nutritive  enemas  with 
brandy,  graduated  according  to  necessity,  administered  every 
few  hours  for  the  first  forty-eight  hours  or  so,  will  tide  the 
patient  over  the  first  stage.  Restlessness  and  jactitation  are 
here  best  treated  by  full  hypodermic  injections  of  morphia. 

All  cases  of  severe  operation  are  of  necessity  followed  by 
more  or  less  peritonitis.  The  symptoms  of  peritonitis  appear 
from  the  second  to  the  fourth  day,  and  manifest  themselves  by 
sickness,  vomiting,  and  tympanitic  distension  of  the  abdomen. 
The  pulse  is  small,  wiry,  and  rapid  ;  the  breathing  is  quick, 
superficial,  and  entirely  costal ;  the  countenance  becomes  dusky, 
the  lips  blue,  and  the  aspect  generally  that  indescribable  but 
characteristic  one  which  is  familiar  to  every  experienced  oper- 
ator. Therapeutic  measures  must  now  be  prompt  and  decisive, 
and  of  vigour  corresponing  to  the  gravity  of  the  case. 

In  the  first  place,  the  administration  of  all  foods,  drinks,  and 
medicines  by  the  mouth  must  be  stopped.  They  are  simply 
vomited,  and  perseverance  in  their  exhibition  is  bootless,  and 
only  worries  the  patient.  A  definite  system  of  feeding  by  the 
rectum  is  at  once  instituted  and  continued.  A  good  routine 
enema  is,  an  ounce  of  brandy,  a  teaspoonful  of  Valentine's 
fluid    meat   or   Brand's   essence  or  Benger's   peptonised  jelly, 


TREATMENT  AFTER    OVARIOTOMY.  153 

and  four  ounces  of  peptonised  milk;,  to  be  administered  every 
five  or  six  hours.  Once  in  the  twenty-four  hours  a  pint  of 
tepid  water  is  passed  into  the  bowel :  much  of  it  is  absorbed 
and  relieves  thirst ;  some  of  it  may  be  returned  with  flatus  and 
the  residues  of  the  enemas.  For  an  hour  or  more  at  a  time 
before  the  period  when  an  enema  is  due  the  rectum-tube  is  worn, 
and  much  flatus  may  pass  through  it.  If  morphia  is  given  at 
all,  it  must  be  given  in  full  doses  and  continuously,  so  as  to 
keep  the  patient  semi-narcotised.  If  the  distension  is  excessive, 
causing  dyspnoea,  a  large  turpentine  enema,  or,  perhaps  better, 
repeated  small  turpentine  enemas  are  of  conspicuous  benefit. 
Though  it  is  not  always  possible  to  give  it  on  account  of  the 
vomiting,  it  must  not  be  forgotten  that  the  greatest  good  will 
probably  follow  a  saline  purge :  liquid  and  flatus  may  be  passed 
in  enormous  quantities,  to  the  patient's  great  relief. 

In  the  worst  cases,  passage  of  the  stomach-tube  may  be 
called  for.  I  have  more  than  once  seen  the  passage  of  this  tube 
in  cases  of  extreme  distension  followed  by  a  forcible  ejection — 
almost  an  explosion — of  fluid  and  gas  that  produced  instan- 
taneous relief.  Once  or  twice  a  day  the  patient  may  be 
encouraged  to  drink  a  large  amount  of  hot  water  or  hot  tea, 
with  the  purpose  of  causing  free  vomiting.  A  free  vomit  is 
less  exhausting  than  continual  retching,  and  it  is  highly  effectual 
in  getting  rid  of  intestinal  accumulations. 

When  it  is  evident,  after  two  days  of  this  treatment,  that  the 
patient  is  losing  ground,  that  the  distension  increases  and  the 
vomiting  continues  unabated,  I  believe  that  we  ought  to  re-open 
the  wound  and  wash  out  the  abdomen  with  a  stream  of  warm 
antiseptic  lotion.  Two  or  three  stitches  at  the  bottom  of  the 
wound  are  removed,  and  two  fingers  are  gently  insinuated 
amongst  the  bowels.  A  celluloid  catheter  attached  to  a  piece 
of  rubber  tubing,  coming  from  a  cistern  elevated  a  few  feet 
above  the  level  of  the  patient,  conveys  the  fluid  into  the  cavity. 
The  fingers  move  the  bowels  about,  while  the  stream  of  fluid 
cleanses  the  peritoneum.  Probably  the  bowels  will  be  glued 
together  at  one  part  or  everywhere  by  soft  adhesions :  these  are 
broken  down  by  the  fingers.     If  a  drainage  tube  has  not  beea 


154  OVARIOTOMY. 

used,  it  is  now  inserted.  It  is  unnecessary  to  sponge  out  the 
peritoneum,  unless  a  collection  of  septic  pus  is  discovered — an 
unlikel}^  accident  in  these  days.  I  believe  that  these  cases  die 
as  much  from  a  form  of  intestinal  obstruction  induced  by  the 
adhesions  and  the  distension,  as  from  mere  peritonitis.  A  sepa- 
ration of  these  adhesions,  setting  the  bowels  free  and  keeping 
them  floating  in  non-irritating  boracic  lotion  or  similar  fluid, 
gives  the  patient  a  chance  of  life  which  is  by  no  means  a  remote 
one.  No  case  ought  to  be  permitted  to  die  without  giving  it 
this  chance  of  recovery. 

With  reference  to  subsidiary  details  in  treatment,  little  need 
be  said.  If  drainage  is  used,  the  sponge  which  collects  the  fluid 
is  changed  as  often  as  necessary,  not  less  frequently  than  twice 
a  day ;  and  the  most  scrupulous  care  is  given  to  keeping  those 
sponges,  and  every  part  with  which  the  fluids  come  into  con- 
tact, sweet  and  pure. 

As  regards  the  temperature,  I  truly  believe  that  it  is  the 
least  important  of  all  the  signs.  Case  after  case  occurs  in 
which  the  temperature  after  the  second  day  becomes  and  con- 
tinues absolutely  normal.  A  rise  on  the  second  day  to  99.5°  or 
100°  is  the  rule  :  in  the  simplest  cases  this  rise  is  usually  higher  ; 
in  the  worst  cases  there  may  be  no  rise  at  all,  or  even  depres- 
sion. It  is  better  to  have  elevation  than  depression  of  tem- 
perature in  the  first  few  days.  A  rise  later  on  indicates  some 
inflammation,  probably  of  a  simple  traumatic  nature  :  the  most 
severe  cases  of  peritonitis  cause  little  elevation.  The  ice-cap 
and  such  devices  for  lowering  abnormal  temperatures  are  very 
rarely  called  for :  probably  a  dose  of  antipyrin  or  thallin  would 
be  preferred. 


Solid  and  Malignant  Growths  of  the  Ovary. 

Solid  tumours  of  the  ovary  are  rare.  Of  all  tumours  of  the 
ovary,  probably  not  more  than  three  per  cent,  are  solid.  Most 
of  them  are  malignant,  sarcoma  or  cancer :  true  myoma  has 
been  found;  pure  fibroma  is  almost  unknown.  Doran  has  never 
met  with  fibroma.  Tait  says  that  "growth  of  the  fibrous  stroma 
of  the  ovary,  so  as  to  form  a  large  abdominal  tumour  requiring 
removal,  has  not  yet  been  described."  I  have,  however,  suc- 
cessfully removed  a  solid  ovarian  tumour  as  large  as  a  child's 
head,  in  which  repeated  examinations  by  competent  histologists 
failed  to  show  any  other  histological  element  than  pure  fibrous 
tissue.  Pain  was  the  most  prominent  symptom  in  this  case. 
Curiousl}^,  in  the  only  other  case  I  have  seen  recorded'''  pain 
was  described  as  being  very  intense.  The  so-called  ovarian 
fibroid  is  usually  a  pure  myoma,  though  we  have  the  authority 
of  Virchow  for  believing  that  considerable  amounts  of  pure 
fibrous  tissue  may  co-exist  with  the  muscular  fibres.  Cysts 
have  been  found  in  these  tumours;  and  Waldeyerf  has  recorded 
a  case  which  was  almost  completel}^  transformed  into  bone. 

Malignant  growths  are  either  sarcomatous  or  cancerous. 
Papilloma  of  the  ovary — a  very  rare  disease — may  also  be 
reckoned  among  malignant  growths.  Sarcoma  is  usually  of 
the  spindle-celled  variety.  The  blood-vessels  are  usually  of 
very  large  dimensions,  giving  the  divided  tumours  almost  a 
cavernous  appearance,  and  cysts  are  frequently  found  contain- 
ing blood  or  serum.  In  one  case  recently  operated  upon,  I 
shelled  out  nearly  a  bucketful  of  blood-clot  from  the  centre  of  a 
sarcomatous  growth.  These  tumours  often  attain  to  enormous 
dimensions,  and  their  existence  is  usually  accompanied  by 
ascitic  fluid,  which  is  often  stained  with  blood. 

Prof.  Leopold];  considers  that  malignancy,  as  a  character  of 
tumours  of  the  ovary,  is  far  more  common  than  is  generally 

*  Ricord,  Lyon.  Med.,  Nov.,  1886.         t  ArcJiiv.  f.  Gyndk,  Bd.  ii.,  p.  440. 
X  Deutsche  Med.  Woch.,  Jan.  4th,  1887. 


156  OVARIOTOMY. 

supposed.  Among  600  ovariotomies  in  Schroeder's  Clinic,  no 
fewer  than  100  are  said  to  have  shown  signs  of  mahgnanc}'; 
and  only  19.5  per  cent,  of  the  cases  operated  upon  remained 
free  from  disease  for  more  than  a  year.  Many  of  these  cases 
were  no  doubt  malignant  disease  grafted  upon  cystic  ovarian 
growths.  Leopold  found  that  in  no  completed  ovariotomies, 
20  (18  per  cent.)  had  malignant  growths.  If  to  these  are  added 
six  cases  where  removal  was  not  completed,  on  account  of  im- 
plication of  neighbouring  structures,  we  have  116  operations  for 
removal  of  ovarian  tumours,  in  which  26  were  found  malignant — 
a  proportion  of  22.4  per  cent.,  greater  even  than  Schroeder's. 
Of  the  cases  where  the  tumour  was  removed,  20  per  cent,  made 
complete  recoveries. 

Butlin*  has  collected  from  the  writings  of  Cohn,  Olshausen, 
Billroth,  and  Thornton  78  cases  of  operation  for  malignant 
diseases  of  the  ovaries  of  various  kinds.  Cohn's  collection  of 
cases  (from  Schroeder's  Clinic),  when  weeded  out,  gave  55,  of 
which  13  died;  Olshausen,  13  cases,  with  3  deaths;  Thornton,. 
10  cases,  with  3  deaths;  Billroth,  21  cases,  with  14  deaths. 
The  general  mortality  was  thus  33  per  cent.  And  the  after- 
results  were  not  very  encouraging,  for  only  5  out  of  47  patients 
whose  cases  could  be  followed  were  alive  and  well  three  years 
after  operation. 

The  results  of  these  operations,  when  carefully  worked 
out,  are  not,  I  suspect,  so  favourable  as  they  are  generally  sup- 
posed to  be.  In  the  first  edition  of  this  work  I  quoted  Cohn's 
statistics!  in  support  of  his  statement  that  the  number  of  per- 
manent cures  would  be  found  about  equal  to  the  number  of 
deaths  after  operation.  This  was  clearly  too  sanguine  an  ex- 
pectation. Still,  a  certain  proportion  do,  apparently,  recover 
permanently ;  and  it  is  reasonable  to  believe  that  this  propor- 
tion would  be  increased  if  operations  were  done  at  the  earliest 
possible  period  after  diagnosis.  And  of  those  cases  in  which 
recurrence  takes  place,  the  subsequent  course  will  usually  be 
less  painful  than  in  cases  not  interfered  with.     As  a  matter  of 

*  Operative  Surg,  of  Malig.  Disease,  London,  1887,  p.  346. 
t  Zeitschr.f.  Geb.  und  Gyn.,  p.  14,  1885. 


DIAGNOSIS   OF  SOLID   OVARIAN   GROWTHS.  157 

fact,  however,  malignancy  is  rarely  diagnosed  till  after  oper- 
ation ;  the  fact  that  so  many  ovarian  tumours  are  malignant  is 
another  and  a  very  strong  argument  in  favour  of  early  operation 
for  all  ovarian  tumours. 

Diagnosis. — Solid  tumours  of  the  ovary  cannot  be  diagnosed 
from  each  other,  and  with  great  difficulty  from  similar  growths 
arising  from  the  uterus.  In  the  case  of  cystic  sarcoma,  the 
diagnosis  from  polycystic  glandular  tumour  and  from  soft 
nodular  uterine  myoma  is  practically  impossible.  Mobility 
and  ascites  are  perhaps  the  most  important  single  features 
pointing  to  solid  ovarian  tumour.  The  rapid  accumulation  of 
ascites  around  a  solid  movable  tumour  that  has  its  deep  attach- 
ment in  the  pelvis  points  to  malignant  disease  of  the  ovary. 
A  round  extra-mural  myoma  may  present  clinical  features  iden- 
tical with  those  of  non-malignant  solid  tumours  of  the  ovary. 
It  is  possible  to  confound  these  growths  with  pregnancy ;  and 
special  care  may  be  necessary  when  vascular  bruits  are  heard 
in  the  tumour.  In  a  majority  of  cases  the  diagnosis  is  not 
completed  till  the  abdomen  has  been  opened. 

Operation. — The  only  peculiarities  of  the  operation  for  solid 
growths  are,  the  length  of  the  incision  which  it  is  necessary  to 
make,  and  the  treatment  of  the  pedicle.  In  average  cases  the 
incision  will  require  to  be  prolonged  above  the  umbilicus. 
When  the  tumour  is  fully  exposed,  it  is  lifted  out  by  means  of 
a  Tait's  handled  screw  placed  in  its  substance.  Removal  is 
helped  by  lateral  movements  of  the  tumour ;  and  the  force  of 
suction,  which  is  often  considerable,  may  be  overcome  by  per- 
mitting air  to  enter  the  cavity  with  fingers  or  hand  carried 
round  the  growth.  As  soon  as  the  growth  is  delivered,  large 
sponges  are  placed  in  the  cavity  to  prevent  extrusion  of  the 
bowels ;  it  may  even  be  expedient  to  insert  a  few  sutures  at  the 
top  of  the  wound  before  doing  anything  else. 

The  pedicle  in  these  cases  is  often  thick,  fleshy,  and  vascular. 
The  Fallopian  tube  does  not  often  form  part  of  it ;  it  is  com- 
posed simply  of  mesovarium.     The   vessels  are  usually  thin- 


158  OVARIOTOMY. 

walled  and  very  large,  so  that  they  are  liable  to  be  injured  by 
transfixion  even  with  blunt  instruments.  Here,  if  anywhere,  a 
second  ligature  below  the  double  perforating  ligature  may  be 
applied  with  advantage.  The  operation  is  completed  and  the 
case  managed  on  the  same  principles  as  an  ordinary  ovariotomy. 
The  removal  of  sarcomatous  cystic  growths  requires  no 
special  description.  The  pedicle  is  usually  very  thick,  and 
peculiarly  inelastic. 


Operations  for   Cystic  Growths  in  the  Broad 
Ligament  and  Parovarium. 

SURGICAL   ANATOMY   OF    THE    BROAD    LIGAMENTS. 

The  broad  ligament  on  each  side  is  composed  of  a  double  layer 
of  peritoneum  enclosing  cellular  tissue  in  which  lie  blood-vessels, 
nerves,  lymphatics  and  muscular  fibres.  The  internal  attach- 
ment is  to  the  side  of  the  uterus  from  the  cornu  to  the  level  of 
the  internal  os ;  the  external  attachment  is  to  the  side  of  the 
pelvis  in  a  vertical  line  about  midway  between  the  obturator 
foramen  and  the  great  sciatic  notch.  Following  its  line  of 
attachment  from  the  cornu  of  the  uterus  to  the  cervix,  the 
following  structures  are  met  with  :  At  the  cornu  is  the  Fallopian 
tube ;  a  little  lower  down  and  more  to  the  front  is  the  round 
ligament,  and  close  to  these  is  the  spermatic  artery;  at  the  bottom 
is  a  space  in  which  lies  the  uterine  artery,  usually  dividing  into 
several  branches  with  numerous  veins,  nerves,  and  lymphatics. 
The  convex  base  of  the  broad  ligament  lies  upon  the  lax  connec- 
tive tissue  which  separates  the  vagina  from  the  fascia  which 
covers  the  levator  ani  muscle.  In  this  tissue  lies  the  large 
uterine  artery,  forming  a  loop  with  its  concavity  upwards  as  it 
courses  between  the  internal  iliac  and  the  neck  of  the  uterus. 
This  vessel  is  likely  to  be  pushed  downwards  by  tumours  grow- 
ing in  the  broad  ligaments;  but  if  the  growth  is  dragged  upwards 
during  removal  it  is  not  out  of  the  range  of  possible  injury. 
The  ureters,  embedded  in  connective  tissue,  pass  from  behind 
forwards  and  inwards  to  the  base  of  the  bladder,  crossing 
obliquely  below  the  base  of  the  broad  ligament.  They  also  are 
not  beyond  the  risk  of  injury.  In  the  pelvic  attachment  no 
vascular  or  other  structures  of  importance  are  found.  It  must 
be  remembered,  however,  that  if  the  broad  ligaments  are  pushed 
apart  by  an  enclosed  tumour,  the  posterior  layer  may  be  forced 
backwards  so  as  to  uncover,  not  only  the  ureter  and  the  uterine 
artery,  but  the  iliac  vessels  as  well. 


160 


OVARIOTOMY. 


The  free  upper  margin  of  the  broad  hgaments,  looked  at  from 
above,  is  broader  at  its  pelvic  than  at  its  uterine  attachment. 
This  is  caused  by  the  divergence  of  the  round  ligament,  which 
curves  forward  to  the  inguinal  opening,  and  which  is  so  far 
removed  from  the  broad  ligament  proper  as  to  be  described  as 
l3'ing  in  separate  folds.  The  position  of  the  ovary  and  tube 
in  their  folds  of  broad  ligament  have  already  been  described. 
The  veins  in  the  broad  ligaments  form  closely-set  plexuses, 
which  are  of  importance  in  relation  to  sub-peritoneal  haematoma. 
The  veins  of  the  uterus,  ovaries,  and  Fallopian  tubes,  after  being 
gathered  together  in  the  pampiniform  plexus,  finally  coalesce 
in  the  internal  spermatic  vein  which  follows  the  course  of  the 
spermatic  artery. 

The  structures  in  and  adjacent  to  the  broad  ligaments  which 
are  liable  to  be  the  starting  points  of  disease  are  admirably 
depicted  in  the  diagram  here  copied  from  Doran's  work. 


Fig.  30. 

Diagram  of  the  Structures  in  and  adjacent  to  the  Broad  Ligament.     (Doran.) 

I.  Framework  of  the  parenchyma  of  the  ovary,  seat  of  la,  simple  or  glandular  multi- 
locular  cyst.  2.  Tissue  of  hilum,  with  3,  papillomatous  cyst.  4.  Broad  ligament  cyst, 
independent  of  parovarium  and  Fallopian  tube.  5.  A  similar  cyst  in  broad  ligament  above 
the  tube,  but  not  connected  with  it.  6.  A  similar  cyst  developed  close  to  7,  ovarian  fimbria 
of  tube.  8.  The  hydatid  of  Morgagni.  9.  Cyst  developed  from  horizontal  tube  of  parovarium. 
Cysts  4,  5,  6,  8  and  9  are  always  lined  internally  with  a  simple  layer  of  endothelium.  10.  The 
parovarium;  the  dotted  lines  represent  the  inner  portion,  always  more  or  less  obsolete  in  the 
adult.  II.  A  small  cyst  developed  from  a  vertical  tube;  cysts  that  have  this  origin,  or  that 
spring  from  the  obsolete  portion,  have  a  lining  of  cubical  or  ciliated  epithelium,  and  tend  to 
develop  papillomatous  growths,  as  do  cysts  in  2,  tissue  of  the  hilum.  12.  The  duct  of  Gartner, 
often  persistent  in  the  adult  as  a  fibrous  cord.  13.  Track  of  that  duct  in  the  uterine  wall ; 
unobliterated  portions  are,  according  to  Coblenz,  the  origin  of  papillomatous  cysts  in  the 
uterus. 


TUMOURS  IN   THE  BROAD   LIGAMENTS.  161 

Opevation  may  be  indicated  in  any  of  the  following  conditions 
residing  in  the  broad  ligaments  : 

(i)  Simple  cysts  of  the  Broad  Ligament.    Parovarian  cysts. 
(2)  Papillomatous  cysts  of  the  Broad  Ligament  and  hilum 
of  the  Ovary. 

In  addition  to  these,  myomata  may  develop  in  the  broad 
ligament  in  connection  with  its  enclosed  muscular  tissue. 
These  are  rarely  of  any  surgical  importance.  The  same  may 
be  said  of  the  small  pedunculated  cysts  attached  between  the 
oviduct  and  the  ovary,  and  arising  from  a  parovarian  tube,  and 
of  those  others  originating  among  the  fimbriae  and  known  as 
Hydatids  of  Morgagni.  Other  diseases  of  great  variety  need 
not  be  described.  One  of  these  has  recently  been  described  by 
Mr.  Taylor  as  having  been  removed  by  Tait,  and  which  con- 
sisted of  several  minute  vesicles  like  those  of  herpes. 


12 


Simple  Cysts  of  the  Broad  Ligament. 

These  are  frequently  described  as  parovarian  cysts.  But  it 
is  now  known  that  many  simple  cysts  developed  in  the  broad 
ligament  do  not  originate  in  the  tubes  of  the  parovarium,  but 
elsewhere  between  its  layers.  The  profoundly  interesting 
questions,  from  a  developmental  as  well  as  a  pathological  point 
of  view,  which  surround  the  origin  of  these  cysts  cannot  here  be 
discussed.  Suffice  it  to  say  that  the  cyst  arising  outside  of  the 
parovarium  is  of  the  simplest  possible  nature,  containing  clear 
fluid  in  a  translucent  wall,  and  not  developing  adventitious  new 
growths  in  its  interior.  According  to  Doran,  it  is  lined  with  flat 
or  low  columnar  epithelium.  Cysts  arising  from  the  tubes  of  the 
parovarium — though  they  are,  in  the  majority  of  instances,  of 
the  simple  character  indicated  above — are  further  peculiar  in 
showing  a  tendency  to  develop  papillomatous  outgrowths  in 
their  interior.  If  of  small  size,  their  lining  may  be  of  ciliated 
epithelium.  According  to  Doran  "  Histologically  and  patho- 
logicall}-,  they  are  identical  with  the  papillary  cysts 
that  appear  in  the  tissue  of  the  hilum  of  the  ovary  where  relics 
of  the  Wolffian  body  exist,  and  do  not  tend  to  invade  the  stroma 
of  the  parenchyma,  but  rapidly  grow  into  the  broad  ligament, 
forcing  apart  its  layers." 

The  leading  surgical  peculiarity  in  these  growths  is,  that  they 
are  unilocular.  No  true  ovarian  cystoma  is  unilocular.  As  a 
rule,  they  grow  away  from  the  broad  ligament,  pushing  aside  the 
ovary  and  the  tube,  and  occasionally  they  exhibit  a  well-marked 
pedicle.  Sometimes,  however,  they  grow  downwards,  widely 
separating  the  layers  of  the  broad  ligament,  and  stretching  out 
the  tube  and  the  ovary  over  their  walls.  They  contain  nearly 
always  a  clear  limpid  fluid  with  but  little  albumen.  Sometimes, 
however,  it  is  thick  or  semi-purulent,  from  inflammation ;  or  dark, 
from  intermixture  with  blood.  Adhesions  are  rare.  Tait  de- 
scribes an  occasional  great  thickening  of  the  cyst-wall  consisting 


TAPPING  163 

of  fusiform  muscular  cells.  Rupture  is  not  infrequent ;  the 
results  are  not  often  serious. 

Diagnosis. — A  parovarian  cyst  is  diagnosed  from  other  cystic 
growths  having  similar  attachments  by  the  laxity  of  its  walls, 
and  the  free  and  rapid  wave  of  fluctuation  which  is  given  on 
palpation.  It  is  perfectly  round  and  globular,  forming,  if  of 
moderate  size,  an  evenly  symmetrical  tumour  in  the  lower 
abdomen.  Its  growth  is  painless  and  unattended  by  symptoms 
of  disturbance  of  the  sexual  organs.  It  is  almost  free  from 
the  dangers  and  complications  which  are  sometimes  found  in 
connection  with  ovarian  cystoma,  and  never  produces  the 
cachexia  which  so  often  accompanies  that  disease. 

The  diagnosis  from  such  conditions  as  ascites  and  renal 
cystic  developments  is  the  same  as  the  diagnosis  of  ovarian 
cystomata  from  these  conditions.  These  being  negatived,  the 
separation  is  then  simply  from  ovarian  growths.  Fibro-cystic 
disease  of  the  uterus  is  a  possible  source  of  confusion. 


THE    OPERATION. 

Tapping. — There  is  no  doubt  that  tapping  may  permanently 
cure  a  simple  cyst  of  the  broad  ligament.  More  than  one 
surgeon  of  repute,  and  particularly  Keith  of  Edinburgh,  em- 
ploys tapping  as  routine  treatment  in  these  cases.  The  C3'st, 
being  emptied,  may  not  refill,  and  the  patient  is  cured  by  the 
simplest  possible  treatment. 

But  objections  may  be  urged  to  this  simple  proceeding.  It 
is  not  always  successful :  some  cysts  refill.  Bantock  had  a  case 
which  was  tapped  seven  times.  Tapping,  even  in  the  most 
skilful  hands,  may  cause  suppuration  in  a  cyst.  But  the  most 
weighty  objection  is  the  fact  that  papillomatous  growths  occa- 
sionally develop  inside  these  cysts,  and  tapping  then  provides 
an  avenue  for  infection  of  the  peritoneum,  a  result  which  is 
inevitably  fatal. 

As  a  counterpoise  to  these  objections,  there  exists  the 
important  fact  that  removal  of  these  growths  is  pecuHarly  free 
from  danger.      If,  in  exceptional  circumstances,  we  may  feel 

12  * 


164  CYSTS  OF  BROAD  LIGAMENT. 

justified  in  giving  the  patient  her  chance  of  cure  by  tapping,  I 
beheve  that  the  best  routine  treatment  in  these  cases  is  removal. 
RemovaL — In  most  cases  of  simple  cyst  of  the  broad  ligament, 
removal  is  a  very  simple  proceeding.  The  parietal  incision  need 
not  be  more  than  an  inch  and  a  half  or  two  inches  in  length. 
The  cyst-wall  is  very  thin  and  easily  torn,  and  fluid  is  very 
liable  to  escape  by  the  side  of  the  trocar.  If  no  special  appliance 
is  used  to  avoid  this,  the  simplest  plan  is  probably  to  lay  aside 
the  trocar,  catch  the  edges  of  the  opening  in  the  cyst-wall  with 
forceps,  pull  them  out  of  the  wound,  and  let  the  fluid  run  over 
the  macintosh  into  the  vessel  on  the  floor.  The  tumour  usually 
is  delivered  without  any  trouble  whatever.  The  pedicle  is  not 
often  long,  but  it  is  rarely  difficult  to  deal  with.  Vessels  are 
neither  abundant  nor  large,  and  the  tissues  are  but  slightly 
hypertrophied.  Though  there  may  be  no  very  strong  objection 
to  leaving  a  portion  of  the  cyst-wall  behind,  the  ligature  should 
always  be  carried  below  the  hmits  of  the  growth.  The  ovary 
and  tube  may  frequently  be  left  behind ;  but  unless  this  can 
easily  be  done,  it  is  best  not  to  complicate  the  operation  in  the 
slightest  degree  by  seeking  to  separate  them.  Besides,  any 
traumatism  applied  to  the  appendages  is  likely  to  beget  trouble 
in  future  by  the  formation  of  adhesions. 

In  those  somewhat  rare  cases  where  the  cyst  grows  between 
the  layers  of  the  broad  ligament,  removal  may  be  attended  with 
considerable  difficulty.  Here  there  is  no  pedicle,  and  the  base 
of  the  cyst  Hes  deep  in  the  pelvis.  The  growth  must  be  dis- 
sected out  from  between  the  layers  of  the  ligament  in  the 
manner  already  described  for  encapsuled  ovarian  growths.  It 
is  usually  best  to  begin  from  thS  side  next  to  the  uterus.  The 
flaccid  cyst-wall  is  pulled  out  of  the  wound,  which  will  have 
been  enlarged  as  far  as  necessary,  the  peritoneal  investment  is 
teased  open,  and  the  wall  of  the  cyst  is  exposed.  The  finger, 
pushed  into  the  cellular  tissue,  separates  the  cyst  from  the  liga- 
ment by  stretching  rather  than  by  tearing.  The  larger  bundles 
of  cellular  tissue  containing  vessels  are  caught  in  catch-forceps 
and  divided  by  scissors  ;  and  this  process  is  repeated,  step  by 
step,  till  the  cyst  is  completely  enucleated  from  its  bed.     As  a 


REMOVAL.  165 

rule  there  is  but  little  haemorrhage.  In  the  deeper  and  outer 
portions,  special  care  must  be  taken  that  the  ureter  or  the  uterine 
artery,  or  any  other  branch  of  the  iliac  vessels,  is  not  injured. 
The  two  flaps  representing  the  layers  of  the  broad  ligament  may, 
according  as  seems  best  at  the  time,  be  either  left  untouched 
or  united  by  suturing  with  or  without  removal  of  portions  of 
them.  In  a  case  of  this  sort,  it  will  be  wise  to  insert  a  glass 
drainage  tube. 


Papillomatous  Cysts  of  the  Broad  Ligament. 

In  a  practical  as  well  as  in  a  pathological  treatise  these  well 
deserve  separate  consideration.  They  are  not  common ;  but. 
from  the  peculiar  and  difficult  nature  of  the  operation  necessary 
for  their  removal,  they  deserve  close  attention. 

The  origin  of  these  growths  is  not  yet  finally  settled.  The 
painstaking  and  able  investigations  of  Doran  leave  little  doubt 
that  a  frequent  and  favourite  starting  point  is  in  the  hilum  of 
the  ovary.  It  is  well  known  that  papilloma  may  develop  in 
parovarian  or  other  cysts  of  the  broad  ligament ;  it  is  certain 
that  growths  arising  from  the  hilum  are  peculiarly  liable  to 
develop  abundant  papillomatous  material.  Papillary  cysts 
may  appear  in  connection  with  the  ovary,  and  may  overgrow 
the  broad  ligaments  and  the  uterus,  but  here  they  exist 
almost  entirely  as  accidental,  and  not  as  ordinary  or  essential, 
concomitants. 

As  a  matter  of  practical  surgery  their  remote  origin  is  of 
little  moment.  What  concerns  us  most  is  the  fact  that  such 
growths  always  burrow  between  the  layers  of  the  broad 
ligament,  and  there  develop  peculiarities  which  may  be  made 
use  of  for  purposes  of  diagnosis,  and  which  make  these  growths 
among  the  most  difficult  to  remove  in  abdominal  surgery. 

In  the  early  stages  the  diagnosis  from  ovarian  cystic  disease 
is  uncertain  or  impossible.  The  clinical  features  of  a  well- 
developed  papillomatous  cyst  are  fairly  distinctive.  These  I 
have  elsewhere  *  described  at  some  length ;  they  may  be  here 
abstracted  as  follows : 

I.  In  their  growth,  papillomatous  C3^sts  of  the  broad  liga- 
ment are  not  symmetrical.  Growing  as  they  do  in  the  broad 
ligament,  and  having  no  pedicle  to  permit  their  escape  from  the 
pelvis,  they  are  fixed  down  on  one  side,  and  cannot,  even  when 
large,  rise  to  the  position  of  least  pressure  in  the  middle  of  the 
abdomen.  Minor  cysts  bulge  out  where  they  can  find  room  in 
*  Annals  of  Surgery,  Dec,  1885. 


CLINICAL   FEATURES.  167 

the  pelvis  or  on  the  side  not  occupied  by  the  main  cyst ;  but 
their  aggregate  bulk  and  arrangement  are  not  such  as  to 
produce  a  balancing  symmetr3\  Ovarian  cystomata  are  not 
so  persistently  one-sided  or  so  irregular  in  shape  as  these, 
and  they  are  not  so  deeply  nor  so  firmly  attached  in  the 
pelvis. 

2.  In  these  cases  there  is  usually  found,  in  addition  to  the 
large  papillary  cyst,  several  small  thin -walled  cysts  packed 
round  the  uterus  and  crossing  to  the  opposite  side  of  the 
abdomen.  It  is  not  a  development  of  a  multilocular  growth, 
one  large  cyst  divided  by  septa  into  several,  but  rather  of 
several  separate  cysts  sessile  on  a  common  base.  These 
secondary  growths  are  usually  very  thin-walled,  and  fluctuate 
freely.  They  can  be  felt  through  the  vagina  in  Douglas's 
pouch,  and  through  the  abdominal  walls,  frequently  overlapped 
by  bowel  on  the  side  opposite  to  the  main  cyst. 

3.  Papillomatous  cysts  of  the  broad  ligament  are  but  slightly 
movable.  In  the  pelvis,  through  the  vagina,  this  sense  of  im- 
mobility is  peculiarly  striking.  The  growths  are  doubly  fixed 
by  the  broad  ligament  in  which  they  lie,  and  by  the  minor  cysts 
packed  in  the  pelvis  which  spring  from  them. 

4.  In  most  of  these  cases  there  is  considerable  enlargement 
and  elevation  of  the  uterus.  That  the  uterus  should  be  enlarged 
is  readily  understood,  from  its  close  ph3^sical  and  vascular  con- 
nection with  the  very  vascular  growth.  That  it  should  be 
elevated  is  a  necessary  consequence  of  the  direction  of  the 
growth  of  the  tumour  which  is  attached  to  it.  This  enlarge- 
ment is  in  excess  of  what  we  find  in  adherent  ovarian  cystoma. 
The  uterus  usually  lies  in  a  deep  sulcus  between  the  major  cyst 
and  the  minor  cysts,  giving  an  appearance  of  two  growths ;  but 
sometimes  it  lies  behind  the  growths,  being  overlapped  by  them. 
The  bladder  may  be  dragged  upwards  with  the  uterus. 

5.  As  a  corollary  from  the  preceding  propositions,  we  might 
infer  physical  interference  with  the  processes  of  defaecation  and 
micturition.  The  enlarging  growth  being  fixed  in  the  pelvis,  of 
necessity  compresses  the  hollow  viscera.  In  one  case  upon 
which    I    successfully   operated    the   frequency   of   micturition 


168  07575   OF  BROAD  LIGAMENT. 

almost  amounted  to  incontinence ;  in  this  case,  the  difficulties 
of  defaecation  more  than  once  amounted  to  positive  obstruction. 
A  curious  feature  in  the  case  of  this  patient  was  that  she  could 
defaecate  only  when  standing  upright,  probably  because  the 
sitting  posture  forced  the  growth  down  into  the  pelvis.  In  two 
other  cases*  troubles  on  micturition  were  considerable,  but  not 
urgent. 

6.  Papillomatous  cysts  are  peculiarly  liable  to  undergo  rup- 
ture. This  is  an  indication  to  operate,  because  of  the  danger 
arising  from  infection  of  the  peritoneum.  In  one  of  my  cases 
there  was  an  extraordinary  and  perhaps  unique  history  of 
rupture  on,  at  least,  twelve  occasions.  Most  of  these  ruptures 
were,  however,  in  my  belief,  confined  to  the  minor  cysts ;  but 
there  is  no  doubt  that  rupture  of  the  papillary  cysts  frequently 
takes  place.  It  is,  however,  more  a  leakage  through  a  small 
opening  than  a  gush  through  a  large  one,  and  the  opening  is 
usually  blocked  by  the  papillary  growths  floating  into  it. 


THE    OPERATION. 

The  first  element  of  danger  in  these  cases  refers  to  the 
possible  elevation  of  the  bladder,  and  the  risk  which  it  thereby 
incurs  of  being  wounded  in  making  the  parietal  incision.  The 
incision  ought  therefore  to  be  made  higher  up  than  usual,  and 
it  should  be  short.  If  the  bladder  is  out  of  the  reach  of  danger, 
the  incision  may  be  prolonged  downwards  to  the  requisite 
distance. 

The  second  peculiarity  refers  to  the  mode  of  tapping  the 
cyst.  It  will  not  always  be  possible  to  bring  the  cyst-wall  to 
the  surface ;  and  as  peritoneal  infection  might  be  caused  by 
the  escape  of  cyst-contents  into  the  peritoneum,  extraordinary 
precautions  must  be  taken  to  collect  all  fluids  which  may  escape 
by  the  side  of  the  trocar.  And  when  no  more  fluid  flows,  the 
opening  must  be  perfectly  closed  by  forceps  or  clamp.  It  is  not 
wise  to  break  down  and  remove  papillomatous  material  by  the 
hand ;  the  bleeding  is  so  free,  and  the  risks  from  escape  of  the 

*  Loc,  Cit. 


REMOVAL.  169 

growth  are  so  serious,  that  it  is  better  to  enlarge  the  incision 
and  dehver  the  tumour  bodily. 

Tapping  of  the  secondary  cysts  is  best  done  by  aspiratbr. 
They  can  rarely  be  brought  to  the  surface,  and  they  are  very 
thin-walled  and  peculiarly  liable  to  be  ruptured  in  manipulation. 
A  large  trocar  attached  to  an  aspirating  bottle  is  inserted, 
sponges  are  placed  round  the  site  of  puncture,  and  the  fluid  is 
drawn  off  from  the  various  cysts  in  succession. 

When  the  cysts  are  emptied  the  process  of  separation  begins. 
It  may  be  impossible  to  tell  where  uterus  ends  and  tumour 
begins,  so  closely  are  they  sometimes  incorporated.  It  may 
therefore  be  wise  to  depute  an  assistant  to  pass  and  manipulate 
the  uterine  sound  as  a  guide.  The  same  may  be  necessary 
in  the  case  of  the  bladder,  especially  if  it  is  empty,  and  its 
walls  are  collapsed  and  flaccid.  Here  the  disadvantage  of  an 
empty  bladder  is  conspicuous.  It  may  even  facilitate  operation 
to  inject  a  few  ounces  of  fluid  into  the  bladder,  so  as  to  accu- 
rately show  its  limits.  The  peritoneum  covering  both  uterus 
and  bladder  may  be  thickened,  movable,  and  very  similar  in 
appearance  to  that  covering  the  growth. 

It  is  impossible  to  give  useful  instructions  as  to  where  the 
process  of  separation  is  to  begin  for  any  case.  This  depends 
upon  the  position  of  the  growth  and  the  nature  of  its  attach- 
ments. If  possible,  I  would  recommend  that  a  beginning  be 
made  near  the  uterus,  so  as  to  cut  off  as  much  of  the  blood 
supply  as  possible  early  in  the  process  of  separation.  A  small 
incision  is  made  by  knife  or  scissors,  the  finger  is  pushed 
through  this  and  rapidly  separates  as  much  of  the  growth  as 
possible.  This  separated  portion  is  either  surrounded  by  liga- 
ture or  caught  in  large  pressure  forceps,  and  the  tissue  cut 
through  beyond.  If  the  operation  can  be  continued  and  com- 
pleted by  repetitions  of  this  process,  it  will  be  much  simplified. 
But  we  must  expect  to  have  to  carry  out  a  much  more  com- 
plicated process  of  dissection,  in  which  scissors,  knife,  forceps, 
ligature,  and  even  actual  cautery,  are  in  constant  requisition. 
I  know  of  nothing  which  more  fully  tries  the  patience  and  skill 
of  the  surgeon  than  such  a  dissection.     At  a  distance  probably 


170  CYSTS  OF  BROAD  LIGAMENT. 

of  several  inches  from  the  surface,  not  easily  seen  and  with 
difficulty  handled,  each  area  of  adhesion  has  to  be  dealt  with 
promptly  and  decisively.  If  the  adhesion  can  be  surrounded 
by  forceps  or  ligature  before  being  divided,  enucleation  is  sim- 
plified. But  often  the  adhesion  must  be  separated  by  fingers 
alone,  and  the  raw  surface  bleeds  freely.  Forceps  must  be 
placed  on  the  bleeding  points  when  they  are  visible :  for  a 
general  oozing  sponge -packing  or  the  cautery  must  be  used. 
In  separating  adhesions  from  the  bladder,  special  care  must  be 
taken  to  avoid  tearing  its  walls ;  and  if  points  bleed  and  forceps 
are  placed  on  them,  we  must  be  particularly  careful  to  see  that 
the  strong  locking  instrument  does  not  grasp  a  piece  of  bladder- 
wall  and  so  cause  a  risk  of  sloughing.  If  the  adhesions  to  the 
posterior  surface  of  the  uterus  are  particularly  strong,  it  may 
facilitate  matters  to  prolong  the  incision  upwards  for  such  a 
distance  as  to  permit  the  whole  to  be  turned  out  over  the  pubes 
with  the  uterus,  and  then  proceed  with  the  parts  in  sight.  In 
one  such  case  I  had  tumour,  enlarged  uterus,  and  greatly  dis- 
tended bladder  lying,  apparently  as  one  homogeneous  mass,  on 
the  macintosh  covering  pubes  and  thighs.  If  this  can  be  done, 
it  greatly  simplifies  operation. 

We  must  expect  to  find  intestine  adherent  to  the  surface  of 
the  growth  and  in  the  sulci  between  the  smaller  cysts  ;  and  here 
special  delicacy  in  separating  must  be  observed.  The  ureter 
too,  and  the  uterine  artery  with  branches  of  the  internal  iliac, 
may  be  within  reach  of  danger,  and  they  must  be  looked  for 
in  manipulations  near  the  lower  and  outer  attachments  of  the 
broad  ligaments. 

The  toilet  of  the  peritoneum  must  be  carried  out  with  par- 
ticular scrupulousness.  Tait's  plan  of  washing  out  the  cavity 
may  here  be  used  with  special  advantage.  The  insertion  of  a 
drainage  tube  will  almost  certainly  be  called  for. 


Removal  of  the  Uterine  Appendages. 

Nomenclature. — The  want  of  a  good  name  for  this  operation 
is  already  being  felt.  At  first,  when  its  object  was  supposed  to 
be  limited  to  the  production  of  an  artificial  menopause,  the 
operation  was  known  as  "normal-ovariotomy."  Battey,  who 
introduced  the  name,  was  among  the  first  to  recognise  its 
unsuitability.  As  a  matter  of  principle,  the  operation  was  by 
no  means  restricted  to  ovaries  that  were  normal ;  and,  as  a 
matter  of  practice,  it  was  found  that  most  of  the  ovaries  re- 
moved were  actuall}-  diseased.  The  term,  "  Battey's  operation," 
while  suitable  within  the  limits  which  Battey  laid  down  for  it, 
does  not  include  the  more  extended  modern  proceedings. 
"  Oophorectomy  "  had  already  been  used  b}'  Peaslee  and  others 
as  a  synon3'm  for  ovariotomy  before  it  was  sought  to  limit  it  to 
removal  of  small  ovaries  ;  and  as  oviducts  are  now,  in  most 
cases  removed  as  well  as  ovaries,  the  term  is  in  a  double  sense 
objectionable.  In  connection  specially  with  disease  of  the 
Fallopian  tubes,  Tait's  name  became  associated  with  removal 
of  the  uterine  appendages ;  and  when,  in  harmon}'^  with  certain 
beliefs  which  he  holds  as  to  the  functions  of  the  oviducts,  he 
practised  removal  of  the  tubes  as  well  as  of  the  ovaries  where 
others  had  been  content  with  removal  of  the  ovaries  alone,  the 
proceeding  of  "  Removal  of  the  Uterine  Appendages  "  came  to 
be  known  as  Tait's  operation.  Men  performed  Tait's  operation 
with  Battey's  motives ;  hence  a  confusion  which  has  been  ren- 
dered more  confounded  by  more  than  one  surgeon  calling  it  the 
"  Battey-Tait  operation."  The  German  terms,  "spaying"  and 
"castration,"  are  objectionable  on  the  grounds  both  of  good 
taste  and  of  exact  naming.  In  many  of  the  operations  performed 
the  effect  of  castration,  as  usually  imderstood,  is  an  undesirable 
accident  rather  than  a  definite  aim.  "Salpingectomy"  for 
removal  of  the  tubes,  and  "  salpingo-oophorectoni)'  "  for  removal 
of  the  appendages,  are  fairly  exact  but  decidedly  cumbrous. 
"  Prosthekotomy  "  is  equally  applicable  to  caudal  and  to  uterine 
appendages.  A  friend  has  suggested  to  me  the  word  "  thely- 
tectomy "   (0/y\i'T/;v  =  feminine  principle);   but  this,  perhaps,  is 


172  REMOVAL    OF  THE    UTERINE  APPENDAGES. 

too  suggestive  of  castration.  Under  any  of  these  names,  it  is 
impossible  to  give  a  complete  account  of  any  recognised  surgical 
operation ;  therefore,  in  place  of  a  better,  the  vague  but  com- 
prehensive title,  "  Removal  of  the  Uterine  Appendages,"  is 
adopted.  Even  to  this  name  the  objection  may  justly  be  raised, 
that  the  uterus  is  an  appendage  to  the  ovaries,  rather  than  the 
ovaries  to  the  uterus.  From  a  surgical  stand-point,  however, 
the  objection  has  less  weight  than  from  a  physiological.  Skene 
of  Brooklyn  *  seeks  to  get  over  the  difficulty  by  the  use  of  the 
term  "  tubo-ovariotomy."  But  ovariotomy  for  tumour  is  also 
"  tubo-ovariotomy "  in  the  sense  which  he  suggests ;  and, 
according  to  ordinary  meanings  of  words,  his  term  might  easily 
be  interpreted  as  meaning  something  very  different  from  what 
was  intended. 

History. — As  a  barbarous  custom,  the  castration  of  women 
dates  from  a  very  remote  antiquity.  In  the  case  of  female 
domestic  animals,  such  as  cows,  camels,  sows,  bitches,  mares, 
and  ewes,  we  have  abundant  evidence  in  the  writings  of  Aris- 
totle, Pliny,  Galen,  Suidas,  and  others,  that  castration  was  very 
generally  practised.  The  practice  is  said  to  have  been  extended 
to  women  at  the  instigation  of  certain  kings  of  Lydia.  Accord- 
ing to  Xanthus,  a  Lydian  historian  who  wrote  in  the  sixth 
century  before  Christ,  the  Lydian  king  Andramyte  first  intro- 
duced female  eunuchs  into  the  service  of  his  palace.  Gyges, 
another  king  of  Lydia,  is  said  to  have  caused  the  removal  of 
ovaries  from  women  with  a  view  to  prolonging  their  charms — 
^^  quo  illis  semper  aetate  florentibus  nteretur.''  Various  authors  have 
thrown  doubt  on  the  reality  of  this  proceeding,  saying  that  the 
so-called  castration  was  either  removal  of  the  uterus  (which  is 
most  improbable),  or  ablation  of  the  nymphse  or  the  clitoris,  or 
even  (which  seems  an  unwarrantable  postulate)  padlocking  or 
"  infibulation,"  a  proceeding  analogous  to  that  which  Celsius 
describes  as  having  been  carried  out  on  boys.  If  the  Lydians 
really  castrated  animals  for  domestic  purposes, — and  of  this 
there  can  scarcely  be  a  doubt, — it  is  quite  within  the  bounds  of 
possibility  that  they  castrated  women  also.  It  is  certainly  unlikely 
*  Diseases  of  Women,  i88g,  p.  509. 


HISTORY.  173 

that  with  the  Lydians  any  other  form  of  mutilation  than  removal 
of  the  ovaries  should  be  considered  as  constituting  castration."-'^ 

Even  in  times  comparatively  modern  it  is  stated  that  the 
practice  has  been  in  vogue  in  Central  Asia.  A  medical  mis- 
sionary, Dr.  Roberts,  is  said  to  have  met,  in  Bombay,  Hedgeras 
— attendants  in  harems — who  were  spayed. f  He  remarks  that 
they  did  not  menstruate,  and  that  they  had  no  sexual  desire. 

The  story  of  the  Hungarian  sow-gelder  who,  in  a  fit  of  parental 
anger,  castrated  his  unchaste  daughter,  is  supported  by  testimony 
of  real  weight.:]:  Schurigius  speaks  of  two  similar  cases;  and 
other  cases,  with  less  weight  of  authority,  have  been  recorded. 

These  ancient  practices  were  not,  however,  therapeutic 
measures.  Among  the  earliest  operations  performed  with  a 
beneficent  purpose  is  that  related  by  Franck  de  Franckenau, 
in  which  an  ovary,  prolapsed  through  a  wound  accidentally 
made  over  the  pubes,  was  successfully  removed.  Percival 
Pott's  well  known  case  of  removal  of  herniated  ovaries  occurred 
in  1756.  Thereafter  the  history  of  the  operation  is  merged  in 
that   of  modern    ovariotomy   for   tumours. 

In  1823  James  Blundell,  of  Guy's  Hospital,  a  man  far  in 
advance  of  his  times,  in  a  paper  read  before  the  Medico- 
Chirurgical  Society  of  London,  suggested  removal  of  healthy 
ovaries  in  cases  of  severe  dysmenorrhcea,  or  metrorrhagia  from 
inverted  uterus.  His  advocacy  of  removal  of  the  whole  uterus 
in  place  of  ordinary  Caesarean  section,  and  the  scientific  manner 
in  which  he  sought  to  sustain  his  arguments  by  experiments  on 
rabbits,  have  scarcely  received  the  attention  which  they  deserve. 
As  more  germane  to  the  subject  in  hand,  special  reference  must 
be  made  to  his  proposed  method  for  producing  sterility  in  cases 

*  Many  classical  writers  of  the  Middle  Ages  refer  to  the  practice.  For 
more  detailed  accounts  see — 

Dujardin,  Hist,  de  hi  Chirurgie.     Paris,  1774. 

Mahon,  Medecinc  Legale  et  Police  Medicale.     Paris,  1801. 

Much  interesting  information  will  be  found  in  the  second  volume  of  Pierre 
Dufour's  laborious  work,  Histoire  de  la  prostitution  chez  tons  Us  peuplcs  dumoiide  ; 
and  a  moderately  full  summary,  with  numerous  references,  is  given  by  Boinet 
in  the  article,  "  Ovariotomie,"  in  the  Did.  Encycl.  des  Sc.  Med. 

t  "  Hedgeras  de  I'Asie  Centrale,"  Journal  VExperience,     1843. 

J  See  particularly  Wierus,  Opera,  lib.  iv.,  cap.  xx. 


174  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

of  malformed  pelvis,  where  Caesarean  section  had  been  called 
for.  His  words  are  as  follows:  "  I  would  advise  an  incision  of 
an  inch  in  length  in  the  linea  alba  above  the  symphysis  pubis  ; 
I  would  advise,  further,  that  the  Fallopian  tube  on  either  side 
should  be  drawn  up  to  this  aperture ;  and,  lastly,  I  should  advise 
that  a  portion  of  the  tube  should  be  removed,  an  operation  easily 
performed,  when  the  woman  would  for  ever  after  be  sterile."* 

Dr.  Robert  Battey,  of  Rome,  Georgia,  generally  gets  the 
credit  of  having  been  the  originator  of  the  operation  as  it  stands 
in  modern  surgery.  In  1865  he  "conceived  the  idea  of  pro- 
ducing an  artificial  menopause  for  the  remedy  of  disease ;  "  but 
he  did  not  publish  his  ideas  till  1872.  In  February,  1872, 
Lawson  Tait  removed  with  complete  success  an  ovary  the  size 
of  a  pigeon's  egg,  which  contained  a  chronic  abscess.  This  he 
claimsf  as  being  "  the  first  record  in  the  history  of  surgery  of 
the  removal  of  a  small  ovary  for  pain."  Encouraged  by  this 
success,  on  August  ist,  1872,  he  successfully  removed  both 
ovaries  for  the  purpose  of  arresting  intractable  haemorrhage.^ 
A  few  days  before  the  date  of  Tait's  second  operation,  Hegar 
operated  on  his  first  case  with  fatal  result.  On  August  17th, 
1872,  Battey  performed  his  first  operation,  which  was  successful, 
and  in  the  following  month  he  published  it.§ 

In  discussing  the  history  of  the  operation,  it  may  be  objected 
that  Tait's  first  operation  was  not  performed  with  the  aim  which 
Battey  proposed.  The  ovary  was  felt  enlarged  in  Douglas's 
pouch ;  and  as  only  one  ovary  was  removed,  the  operation  was 
not  intended  to  "produce  an  artificial  menopause."  There  is 
no  suggestion  that  the  proceeding  was  the  fruit  of  any  precon- 
ceived theory ;  it  was  a  local  operation  for  a  local  disease.  But 
who  shall  say  of  the  original  work  of  a  practical  man  that  it 
was  not  preceded  by  theory  ?  Tait's  second  case  was  un- 
doubtedly  a   physiological    and    pathological   experiment ;    in 

*  Principlis  and  Practice  of  Obstetricy,  p.  580.   Ed.  by  Th.  Castle.  London,  1834. 

t  Dis.  of  Ovaries,  4th  Ed.,  p.  324. 

\  By  some  mistake  Battey  records  this  case  as  being  fatal.     Trans,  Internat. 
Med.  Congress,  vol.  iv.,  p.  287.     Lond.,  1881. 

§  Atliinta  Med.  and  Surg.  Journal,  Sept.,  1872,  p.  321. 


AIM   OF  THE   OPERATION.  1  75 

favour  of  its  probable  success  only  theoretical  reasons  could 
be  advanced.  Hegar,  too,  must  have  independently  thought 
out  the  operation ;  it  has  certainly  been  his  fortune  materially  to 
influence  its  progress.  To  claim  a  priority  measured  by  days  or 
months  is  to  be  exact  at  the  expense  of  liberality  or  even  of 
justice ;  the  time  was  ripe  for  the  operation,  and  three  inde- 
pendent workers — Battey,  Tait,  and  Hegar — may  be  permitted 
to  share  the  honour  of  introducing  it. 

As  might  be  expected,  the  work  of  these  three  men  has 
tended  to  run  in  different  directions.  Battey's  name  has  con- 
tinued to  be  associated  chiefly  with  the  operation  as  performed 
for  what  may  loosely  be  called  "neuroses."  Tait's  name  is 
mainly  connected  with  inflammatory  diseases  of  the  tubes,  and 
his  influence  has  been  strongly  felt  in  the  substitution  of  opera- 
tion for  actual  disease  as  against  vague  nerve-sj^mptoms. 
Hegar,  again,  is  best  known  in  connection  with  the  operation 
for  uterine  m3'oma.  Trenholme,  in  January,  1876,  claims  to  have 
been  actually  the  first  to  remove  ovaries  for  bleeding  myoma ; 
but  his  influence  has  not  been  so  great  as  that  of  others. 

The  practice  of  numerous  followers  in  the  footsteps  of  these 
pioneers  has  widened  the  range  of  the  operation,  at  the  same 
time  that  it  has  narrowed  down  its  indications.  Greater  exact- 
itude in  diagnosis,  and  increasing  knowledge  in  pathology, 
have  largely  replaced  functional  neuroses  by  palpable  disease. 
Except  for  uterine  myoma,  the  field  for  spaying,  properly  so- 
called,  is  being  greatly  narrowed ;  on  the  other  hand,  the  field 
for  the  removal  of  incurably  diseased  organs  is  being  immensely 
widened. 

The  Aim  of  the  Operation. — The  purpose  of  the  operation,  as 
enunciated  by  Battey,  was  "to  determine  the  change  of  life  for 
any  grave  disease  which  is  incurable  without  it,  and  which  is 
curable  with  it."  Though  this  definition  may  have  held  good 
for  his  own  operation  in  its  first  conception,  it  is  obviously 
imperfect  as  regards  the  operation  in  its  modern  development. 
In  fact,  a  complete  change  of  front  would  probably  cover  more 
cases ;  it  would  certainly  be  more  correct  to  say  that  removal  of 


176  REMOVAL   OF   THE   UTERINE   APPENDAGES. 

the  uterine  appendages  is  performed  for  local  disease  in  the 
ovaries  or  tubes,  than  that  it  is  done  "to  determine  the  change 
of  life."  But  the  operation  has  more  than  one  aim  ;  the  defi- 
nition of  its  purpose  cannot  be  gathered  into  one  sentence.  It 
has  a  threefold  purpose:  (i)  to  remove  organs  incurably  dis- 
eased ;  (2)  to  check  or  modify  the  discharge  of  blood  from 
the  uterus ;  and  (3)  to  completely  abrogate  the  process  of 
ovulation. 

1.  The  removal  of  organs  incurably  diseased,  and  causing 
danger  to  life  or  serious  disablement,  is,  undoubtedly,  the  most 
justifiable  aim  of  the  operation.  Under  this  head  we  have  to 
deal  with  such  conditions  as  abscess  in  the  ovaries  or  tubes, 
Fallopian  pregnancy,  and  strangulated  ovarian  hernia  which 
cannot  be  reduced ;  these  endanger  life :  also  with  the  various 
cystic  diseases  of  the  tubes,  the  more  chronic  and  subacute 
inflammations  of  the  ovaries,  and  their  displacements ;  these 
cause  disablement  in  varying  degrees. 

2.  It  may  be  necessary  to  check  bleeding  from  the  uterus, 
either  on  account  of  its  being  excessive  in  amount,  or  because 
its  discharge  is  attended  with  danger  or  great  pain.  Uterine 
myoma  is  the  chief  cause  of  metrorrhagia ;  incurable  obstruc- 
tion in  the  vagina  or  elsewhere  to  the  menstrual  flow  causes  both 
pain  and  danger ;  and  certain  malformations  and  malpositions 
of  the  uterus  may  be  attended  with  so  much  pain  at  menstrual 
periods  as  to  render  life  a  sort  of  recurrent  martyrdom. 

3.  To  unsex  the  woman— the  aim  sought  when  castration  is 
spoken  of — is  the  least  definite  and  the  least  satisfactory  purpose 
of  the  operation.  The  ill-defined  class  of  so-called  reflex 
neuroses  is  not  here  specially  meant ;  all,  or  at  least  the  great 
majority  of,  inflammatory  diseases  of  the  appendages  are 
attended  by  "  reflex  neuroses."  Here  we  particularly  refer  to 
actual  nerve  diseases,  such  as  mania  or  epilepsy,  which  we 
have  reason  to  believe  are  either  caused  or  kept  up  by  the 
processes  attendant  on  ovulation. 

These  theoretical  "aims  for  operation"  will  be  put  into 
actual  concrete  and  positive  "  indications  "  when  the  diseased 
conditions  are  specified  and  described.     But  with  the  purpose 


OBJECTIONS   TO  THE   OPERATION.  177 

sought  we  must  reckon  the  result  achieved;  and  this  result 
often  oversteps  the  purpose.  We  may  desire  to  put  a  stop  only 
to  that  part  of  the  sexual  process  which  consists  in  the  dis- 
charge of  blood  from  the  uterus,  whereas  the  actual  effect  of 
operation  is  to  strike  at  the  root  of  the  whole  function  of  ovula- 
tion and  destroy  it.  What  exactly  is  the  value  of  this  per  contra, 
which  we  have  to  reckon  with  ? 

Here  we  have  to  deal  with  sentiment  as  well  as  with  science. 
The  question  is  dragged  hither  and  thither  between  the  prac- 
tical enthusiasm  of  the  operating  surgeon  and  the  destructive 
criticism  of  the  arm-chair  theorist.  It  is  the  pride  and  glory  of 
abdominal  surgery  that  it  lives  and  thrives  upon  statistics  ;  and 
it  is,  perhaps,  true  that  some  men  ask  us  to  estimate  their  capa- 
city in  general  by  their  experience  in  detail.  This  is  a  fault, 
but  it  is  a  fault  in  the  right  direction.  And  here  the  legal 
maxim,  ^^  Ex  ahiisu  non  argiiitur  in  imim,"  holds  true.  The  evils 
produced  by  some  men  doing  too  much  will  never  be  counter- 
balanced by  other  men  doing  too  little. 

Practical  men  care  little  for  fine-spun  theories  ;  they  want  to 
get  their  patients  well.  If  objection  is  taken  to  the  operation 
on  the  ground  of  the  loss  of  sexual  feeling,  they  say  that  this  is 
a  petty  and  contemptible  thing  to  be  weighed  against  prolonged 
suffering.  If  loss  of  the  power  of  reproduction  is  the  com- 
plaint, this  is  a  weighty  reason, — one  in  which  those  first 
interested  must  have  the  last  word.  Put  to  the  patient  herself, 
or  to  her  husband,  these  objections — if  the  case  is  one  in  which 
operation  ought  ever  to  be  contemplated — are  usually  promptly 
and  summarily  dismissed.  And  when  the  actual  fact — that  the 
womanly  attributes  are  lost  no  more  after  the  artificial  than 
after  the  natural  menopause — is  borne  in  mind,  the  objections 
have  still  less  weight.  In  most  cases,  child-bearing  was  either 
impossible  or  dangerous  :  here  there  is  no  loss;  and,  in  many, 
dyspareunia  is  changed  into  eupareunia :  here  there  is  a  gain. 
The  general  effects  of  the  operation  are  nowhere  better  ex- 
pressed than  by  Koeberle,  as  translated  by  Barnes:*  "The 
subjects  may  be  regarded  as  women  who  have  suddenly  attained 

*  "  On  Hernia  of  the  Ovary,"  Am.  Joimi.  Obsiet.,  January,  1883,  p.  22. 

13 


178  REMOVAL   OF   THE    UTERINE  APPENDAGES. 

the  menopause.  The  affective  sentiments  remain  untouched. 
They  are  no  longer  under  the  dominion  of  an  imperious  erotic 
want ;  but  they  are  not  the  less  good,  loving  towards  relatives 
and  husband.  The  genital  organs  remain  excitable ;  the  cha- 
racter becomes  gentler,  less  irascible;  the  breasts  do  not  atrophy; 
the  tone  and  voice  are  unaltered."  In  one  sentence,  the  change 
is  one  froni  active  uxoriousness  to  staid,  gentle  matronliness. 
There  is  nothing  very  repulsive  in  this.  Here,  so  far,  the 
matter  ma}^  rest.  The  definite  results  for  the  definite  diseases 
will  be  indicated  further  on. 

Considerations  that  ought  to  have  at  least  as  much  weight 
as  the  ethical  or  sentimental  ones  just  mentioned  are,  firstly,  the 
danger  of  the  operation  itself,  and,  secondly,  the  not  absolute 
certainty  as  to  permanent  cure  among  cases  that  recover.  The 
average  operator  cannot  count  upon  a  mortality  of  less  than 
8  per  cent. ;  and,  as  results  go,  he  may  expect  a  perfect  cure  in 
no  more  than  go  per  cent,  of  all  the  cases  that  recover  from  the 
operation.  These  are  grave  facts  to  be  dealt  with  in  an  opera- 
tion not  always  intended  to  save  life.  The  patient  may  be 
suffering  a  prolonged  martyrdom  ;  but  a  surgical  operation 
which  does  not  bring  cure  is  scarcely  a  respite,  and  death  is 
a  terrible  penalty  to  pay  for  relief.  On  these  grounds  we  ought 
to  be  assured,  in  the  first  place,  that  there  is  a  clear  case  for 
operation ;  and,  in  the  second  place,  that  the  full  ratio  of 
probability  of  favourable  result  belongs  to  the  case  under 
consideration. 


CONDITIONS    INDICATING    OPERATION. 

The  disease — the  extent  of  it  and  the  symptoms  which 
it  produces — is  the  final  criterion  as  to  operative  interference. 
It  serves  no  good  scientific  purpose  to  describe  a  symptom 
as  a  cause  of  operation ;  it  is  unfortunate  that  so  many 
operations  are  recorded  as  being  for  ovaralgia,  dysmenorrhoea, 
and  such  hke.  The  evil  has  not  been  diminished  by  the 
recent  appearance  of  certain  valuable  papers  in  German 
periodicals,   entitled   "  Castration  for   Neurosis."      In  most  of 


INDICATIONS  FOR   OPERATION.  179 

the  cases  described  pain  was  the  only  neurosis,  and  in  most 
of  them  also  there  was  actual  disease  in  the  appendages.  It 
is  just  as  scientific  to  speak  of  excision  of  the  hip  for  reflex 
pain  in  the  knee,  as  of  excision  of  the  appendages  for  reflex 
pain  in  the  back.  Wherever  it  is  possible  the  disease  ought  to 
be  quoted  as  the  cause  for  operation,  and  not  the  symptoms  of 
it.  In  a  small  and  diminishing  class  of  cases  a  profound  neu- 
rosis, mania  or  epilepsy,  may,  under  very  special  restrictions, 
be  quoted  as  an  indication  to  operation.  Yet  even  in  these,  with 
a  curious  frequency,  disease  of  the  organs  is  found  at  operation. 
For  the  rest,  the  disease  will  be  spoken  of  as  the  indication  for 
operation.  Thus,  instead  of  speaking  of  removal  of  the  ap- 
pendages for  ovaralgia,  dysmenorrhcea,  or  menorrhagia,  we 
speak  of  the  operation  as  being  for  ovaritis,  pyosalpinx,  or 
myoma.  With  this  view  the  indications  for  operation  may  in 
skeleton  outline  be  presented  as  follows : 

A — The  Appendages. 

(i)  The  Ovaries. 

(a)  Inflammation  —  acute,     chronic,    and    suppurative 

(abscess). 

(b)  Displacement  (prolapse,  hernia). 

(c)  Cirrhotic  and  C3'stic  ovaries. 
(2)  The  Fallopian  Tiihes. 

{a)  Inflammation — Salpingitis. 

ib)  Pyosalpinx. 

{c)  Haematosalpinx. 

(d)  Hydrosalpinx. 

{e)  Fallopian  pregnancy. 

B — The  Uterus. 

{a)  Uterine  myoma. 

[b]  Errors  of  development  —  absence  or  mal-develop- 

ment  of  uterus  with  menstrual  molimen. 
{c)  Incurable   displacements   with  severe  nerve-symp- 
toms. 
{d)  Insuperable   obstruction   to   menstrual    flow    (may 
reside  in  vagina). 
13  - 


180  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

C — The  Nervous  System. 

(a)  Mania ;  puerperal  mania,  menstro-mania,  nympho- 
mania, &c. 

(i)  Epilepsy ;  hystero-epileps}',  convulsions,  cramps^ 
dancing  fits,  &c. 

(c)  Hysteria. 

It  need  scarcely  be  pointed  out  that  the  mere  existence  of 
any  of  these  abnormal  conditions  is  (with  possible  exceptions  in 
the  case  of  three  or  four  of  them)  no  indication  for  operation. 
The  essential  concomitants  of  these  diseases  must  be  of  a  grave 
nature — there  must  be  danger  to  life  or  serious  impairment  of 
health — before  operation  is  contemplated.  With  this  prelimi- 
nary and  comprehensive  proviso  we  may  proceed  to  consider 
the  indications  in  detail. 

Ovaritis,  Oophoritis,  Inflammation  of  the  Ovaries. — The  chronic 
form  of  ovaritis  arising  from  excessive  functional  activity,  which 
is  found  in  prostitutes,  rarely  calls  for  operation.  So  also  those 
temporary  acute  congestions,  as  obscure  in  origin  as  they  are  in 
pathology,  require  no  notice.  The  majority  of  cases  requiring 
operation  have  their  origin  in  gonorrhoea.  Septic  matter  may 
be  carried  along  the  tubes  to  the  ovaries  by  puerperal  inflam- 
mation in  the  uterus,  and  there  is  no  doubt  that  a  septic  catarrh 
of  the  endometrium  set  up  by  traumatism,  as  from  the  sound  or 
tangle  tent,  may  also  be  a  cause.  The  exanthematic  fevers  and 
acute  rheumatism  sometimes  beget  a  form  of  ovaritis  which  is 
attended  with  troublesome  symptoms.  Cases  following  septic 
inflammations  at  childbirth  always  pursue  a  rapid  course  and 
eventuate  in  abscess,  which  may  be  rapidly  or  even  suddenl}^ 
fatal,  or  may  pursue  a  more  chronic  course,  bursting  into  one  or 
other  of  the  neighbouring  hollow  organs.  Following  gonorrhoea, 
or  simple  traumatism,  or  any  of  the  exanthemata,  ovaritis  is 
liable  to  become  very  chronic,  and  here  indications  to  operate 
are  most  frequent  and  most  legitimate. 

In  such  cases  the  local  signs  may  be  marked  enough,  but 
urgency  is  usually  bespoken  by  the  reflex  or  the  functional 
symptoms.     The  ovary  is  exquisitely  tender  to  all  mechanical 


DISPLACEMENTS  OF  THE   OVARY.  181 

disturbance,  when  the  patient  stands  or  moves  quickly,  and 
it  drags  on  its  ligaments  or  is  jerked  ;  and  when  it  is  pressed 
upon  by  the  fingers  through  vagina  or  parietes.  Engorgement 
at  the  menstrual  period  aggravates  the  pain.  In  the  intervals 
also  it  causes  pain,  local  on  various  provocations,  and  outlying 
and  reflex  in  the  groins,  in  the  back,  down  the  thigh,  in  the 
hypochondrium,  and  elsewhere.  Almost  every  known  form  of 
functional  sexual  derangement  may  be  associated  with  ovaritis — 
dysmenorrhoea,  menorrhagia,  amenorrhcea. 

Some  weight  must  be  given  to  the  physical  signs.  An 
inflamed  ovary  has  a  tendency  to  fall  downwards  into  Douglas's 
pouch  and  to  become  fixed  there.  Here  it  may  be  felt  exquisitely 
tender,  and  sometimes  causing  a  peculiar  feeling  of  nausea  on 
being  pressed  upon.  In  this  situation  it  may  rea;dily  be  mistaken 
for  the  fundus  of  a  retroverted  uterus.  A  skilled  diagnostician 
will  at  once  recognise  the  shape  and  consistency  of  the  ovary ; 
he  may  even  palpate  its  ligaments,  and  with  a  high  degree 
of  probability  diagnose  the  presence  of  fluid  or  cysts  in  its 
substance.  In  thin  patients  the  unprolapsed  ovary  may 
be  palpated  between  the  fingers  in  the  vagina  and  on  the 
parietes. 

In  a  case  diagnosed  as  chronic  ovaritis,  from  whatever  cause 
arising,  if  remedial  treatment  has  had  a  full  and  fair  trial,  and 
if  the  patient's  health  is  being  undermined  by  the  constant  pain 
and  other  accompaniments,  operation  may  be  recommended. 
If  abscess  exists,  life  is  endangered  and  operation  is  imperative. 
In  the  former  case  the  indication  follows  on  the  gravity  of  the 
symptoms ;  in  the  latter,  the  indication  is  positive  and  absolute 
on  the  existence  of  the  disease. 

Displacements  of  the  Ovary — Hernia :  Prolapse. — Among  the  first, 
if  not  actually  the  first,  oophorectomies  for  a  beneficent  pur- 
pose were  one  for  hernia  of  the  ovaries  through  a  wound,  and  one 
for  hernia  into  the  inguinal  canal.  Hernia  in  itself  is  not  an 
indication  for  operation.  The  herniated  organs  must  be  irre- 
ducible or  the  source  of  great  pain,  or  the  seat  of  some  form  of 
degenerative  or  inflammatory  disease,  before  operation  is  con- 


182  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

teniplated.  A  traumatic  hernia  following  strain  or  parturition 
is  not  so  likely  to  be  attended  with  troublesome  symptoms  as  a 
congenital  hernia.  The  latter  variety  is  twice  as  frequent  as 
the  former,  and  is  usually  not  of  so  simple  a  nature.  Congenital 
hernia  always  contains  tube  as  well  as  ovary;  not  infrequently 
it  is  associated  with  uterus  bicornis,  and  one  horn  of  the  uterus 
occasionally-  follows  the  appendages  into  the  hernial  sac ;  also 
under-developed  uterus,  with  its  accompanying  symytoms  of 
aggravated  molimina,  may  complicate  the  condition.  In  at 
least  six  cases  complete  absence  of  the  uterus  has  been  noted 
as  accompanying  inguinal  ovarian  hernia. 

The  diagnosis  is  not  often  difficult.  The  characteristic  siz& 
and  shape,  the  sensations  upon  pressure,  the  increase  in  size  at 
the  menstrual  periods,  and  the  frequent  association  with  mal- 
formations of  the  uterus,  form  a  combination  Vv^hich  can  scarcely 
be  imitated  by  any  other  condition.  A  sign  of  importance, 
where  it  can  be  elicited,  is  an  associated  movement  with  lateral 
displacement  of  the  uterus. 

The  tumour  increases  in  size  at  the  periods,  and  becomes 
more  tender.  Then  the  symptoms  may  mimic  those  of  strangu- 
lated hernia.  Actual  strangulation  may  take  place,  and  then 
operation  is  imperative.  So  also  if  extra-uterine  pregnancy 
takes  place  in  the  sac,  an  occurrence  of  curious  frequency, 
operation  is  indicated.  And  any  degenerative  or  novel  develop- 
ment in  its  tissue,  cystic  or  glandular,  demands  operation. 
Otherwise  the  indications  rest  upon  its  resistance  to  palliative 
measures,  its  irreducibiHty,  and  the  urgency  of  the  symptoms 
which  it  produces. 

Prolapse  of  the  ovaries  is  a  condition  by  no  means  always 
demanding  surgical  interference ;  it  is  often  accidentally  dis- 
covered during  examination  for  other  purposes.  Symptoms  of 
urgency  are  produced  only  when  they  become  inflamed  or  are 
bound  down  by  adhesions.  The  existence  of  adhesions  between 
mobile  abdominal  organs  as  a  cause  of  pain,  or  other  abnormal 
symptoms  which  may  be  of  grave  import,  has  probably  not 
received  the  attention  which  it  deserves ;  in  the  case  of  the 
ovary,  from    the   nature  of  the   organ,  it  is  certain  that   this 


CYSTIC  OVARIES.  183 

condition  is  peculiarly  liable  to  breed  trouble.  Adhesions  in 
Douglas's  pouch  are  most  common,  but  the}^  may  be  attached  to 
almost  any  part  of  the  intestinal  or  pelvic  peritoneum.  I  have 
successfully  operated  upon  a  case  where  the  left  ovary  was 
closely  adherent  on  one  side  to  the  sigmoid  flexure,  and  on  the 
other  to  the  tip  of  the  vermiform  appendix.  The  ovary  being 
dragged  upon  between  those  restless  organs,  it  was  not  surprising 
that  acute  symptoms  of  ovarian  irritation  were  produced.  Some- 
times mere  prolapse  started  by  congestion  may  be  continued  by 
a  sort  of  strangulation  of  the  blood  supply ;  in  such  cases  oper- 
ation may  be  required,  though  no  adhesions  exist.  Oophorraphy, 
or  fixation  of  the  ovary  by  a  special  proceeding,  has  been 
devised  to  meet  this  condition ;  the  value  of  it  has  yet  to 
be  decided.  The  left  ovary  is  more  frequently  prolapsed 
than  the  right,  probably  because  it  is  more  liable  to  become 
congested  on  account  of  the  left  ovarian  vein  having  no 
valve. 

Cystic  and  Cirrhotic  Ovaries. — Though  it  is  probable  that  small 
cystic  ovaries  have  their  origin  in  chronic  inflammation,  and  it 
is  almost  certain  that  cirrhosis  or  fibroid  thickening  of  the 
ovaries  claims  this  cause,  yet  in  actual  practice  the  condition  is 
not  found  to  be  inflammatory.  In  the  cystic  ovary  the  disease 
is  not  that  of  ordinary  cystoma — a  glandular  new  growth,  but 
simply  a  distension  of  follicles  in  the  thickened  and  contracted 
stroma.  In  true  cirrhosis  the  gland  tissue  is  replaced,  in  whole 
or  in  great  part,  by  fibrous  material ;  the  surface  is  puckered 
and  scarred,  and  the  size  of  the  organ  is  diminished.  It  would 
seem  that  one  termination  of  the  ovaritis  found  after  the  ex- 
anthemata, especially  after  scarlet  fever,  is  in  this  cirrhotic 
atrophy  with  follicular  distension.  The  pathology  of  this 
condition  is  still  but  ill  understood. 

It  is  a  clinical  fact  that  small  cystic  ovaries  are  often 
attended  with  profuse  and  uncontrollable  menorrhagia.  On 
the  other  hand,  pure  cirrhotic  atrophy  may  be  accompanied  by 
amenorrhoea,  though  the  molimina  may  be  excessively  severe. 
In   many  all   the  varied  and  shifting   symptoms   of  deranged 


184  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

sexual  function  are  present  in  their  most  aggravated  forms. 
And  in  such — parti}',  no  doubt,  because  local  disease  cannot  be 
physically  made  out — ovarian  neuroses  are  abundantly  called  in 
to  justify  operation.  Taking  Schmalfuss's  statistics  of  Hegar's 
operations  as  fairly  representative,  quite  one-half  of  the  so-called 
functional  neuroses  own  such  parench3miatous  changes  in  the 
ovaries  as  causes. 

These  cases  run  a  very  prolonged  course  ;  they  are  peculiarly 
resistant  to  palliative  measures,  and  the  reflex  disturbances  are 
liable  to  be  marked  and  numerous.  If  the  patient  cannot  put 
up  with  her  troubles,  and  the  menopause  is  not  near,  operation 
may  be  performed  :  it  is  the  only  cure. 

Diseases  of  the  Fallopian  Tabes. — Half  a  century  ago,  diseases 
of  the  Fallopian  tubes  were  well  described  by  more  than  one 
writer ;  ■■'■  but  so  completely  had  all  knowledge  of  them  dropped 
out  of  mind,  that  when,  a  little  while  ago,  a  distinguished  pro- 
vincial surgeon  published  results  of  operations  for  such  diseases, 
an  equally  distinguished  metropolitan  brother  expressed  a  some- 
what emphatic  disbelief,  not  only  in  the  operation,  but  in  the 
diseases  as  well.  It  betokened  an  extraordinar}^,  and  almost 
discreditable,  ignorance  of  the  work  of  our  predecessors  that 
Tait  found  it  necessary  to  send  far  and  near  specimens  of  these 
diseases,  in  order  to  establish  a  belief  in  their  reality.  It  is  well 
enough  known  now  that  diseases  of  the  oviducts  are  a  prolific 
cause  of  serious  functional  disturbances,  and  that  the}^  may  even 
cause  death.  The  difficulties  are  now  not  so  much  theoretical 
as  practical :  how  to  diagnose  them,  and  how  best  to  treat 
them;  when  palliative  measures  may  be  persevered  in,  and 
when  operation  becomes  necessary. 

Clincally,  it  is  impossible  to  separate  simple  salpingitis  from 
haematosalpinx  and  pyosalpinx.  The  last  two  may,  in  fact,  be 
considered  as  varieties  of  the  first.  When  the  septic  inflam- 
mation reaches  the  fimbriae,  it  binds  them  together  and  to  the 

*  In  Dekker's  Excrcitationes  Practice,  published  at  Leyden  in  1695,  there  is 
a  description  of  a  case  of  Fallopian  distension,  with  a  highly  artistic  drawing 
of  the  state  of  parts  found  after  death. 


SALPINGITIS.  185 

ovaries,  sealing  up  the  opening.  The  opening  into  the  uterus  is 
either  closed  or  too  small  to  permit  exit  to  all  the  fluid  ;  thus  we 
have  catarrhal  inflammation  in  a  closed  sac,  the  mucous  lining 
of  which  bleeds  every  month.  While  the  peritoneal  covering 
exhibits  the  usual  changes  consequent  on  inflammations  of 
serous  surfaces,  the  cavity  may  contain  blood  or  pus  or  a  mix- 
ture of  both.  The  amount  of  the  blood  or  pus  contained  in 
the  tube  varies  greatly.  Sometimes  it  may  be  less  than  a 
drachm  :  collections  of  blood  rarely  exceed  an  ounce.  I  have 
removed  a  Fallopian  abscess  which  contained  more  than  a  pint 
of  putrid  pus  along  with  a  considerable  amount  of  gas. 

Most  cases  of  salpingitis  are  septic,  the  result  of  inflam- 
mations of  the  endometrium,  gonorrhoeal  or  puerperal.  Some 
cases  originate  in  leucorrhoea,  and  in  such  Wylie  tells  us  he 
has,  by  squeezing  the  tubes,  made  the  pus  flow  into  the  uterus 
and  appear  in  the  vagina.  A  few  are  caused  by  S3^philis  ;  some 
are  tubercular.  Sanger  has  found  actinomycosis  as  a  cause  of 
suppuration. 

Martin"  of  Berlin  has  made  an  elaborate  study  of  tubal 
disease  from  a  collection  of  287  cases.  The  great  majority  (220) 
were  married;  113  were  barren;  61  had  aborted  once  or 
oftener.  The  causes  were,  in  147  cases,  acute  or  chronic  en- 
dometritis ;  in  70,  puerperal  inflammations ;  in  ^^,  gonorrhoea ; 
in  3,  syphilis;  and  in  10,  tubercle.  Tubal  inflammations  Martin 
divides  into  Salpingitis  Catarrhalis,  where  there  is  infiltration 
into  the  mucous  membrane;  Salpingitis  Interstitialis,  where  the 
muscular  coat  is  involved  ;  and  Salpingitis  Follicularis,  where 
pouches  are  formed  on  the  surface  of  the  mucous  membrane. 
The  whole  question  of  gonorrhoeal  inflammation  in  its  bearing 
on  tubal  disease  has  been  treated  in  a  masterly  and  almost 
exhaustive  manner  by  Sinclair  of  Manchester,!  and  to  his  papers 
I  must  refer  my  readers. 

An  inflamed  and  engorged  or  distended  tube  usually  falls 
downwards  into  Douglas's  pouch,  and  becomes  more  or  less 
intimately  adherent  there.  By  the  vagina  it  may  be  felt  as  a 
moderately  soft,  boggy,  irregularly  rounded  tumour,  not  unlike 

*  Zeitschr.  f.  Geburt.,  XIII.,  ii.      \  Med.  CJiron.,  Aug.,  Sept.,  Oct.,  1887. 


186  REMOVAL   OF   THE    UTERINE  APPENDAGES. 

the  fundus  of  a  retroverted  uterus.  It  is  exquisitely  tender  to 
the  touch,  causing  dyspareunia,  and  cannot  readily  be  pushed 
upwards.  Attacks  of  pelvic  pain,  greatly  increased  at  the 
periods,  but  aggravated  at  other  times  with  or  without  provo- 
cation, accompany  the  complaint.  Menstruation  is  fitful  and 
irregular,  usually  increased  but  sometimes  diminished  in  flow. 
Each  period,  in  haematosalpinx,  adds  to  the  danger  as  well  as 
to  the  pain.  Most  cases  occur  in  married  women,  and,  according 
to  Tail,  "  a  very  frequent  feature  in  the  history  of  the  cases  was 
found  to  be  that  they  had  one  child,  and  after  that  were  never 
free  from  pain  till  relieved  by  the  operation." 

In  every  case  of  true  and  persistent  salpingitis  operation  is 
indicated.  With  judicious  treatment  and  rest,  mild  cases  may 
get  well ;  but  when  the  ends  of  the  tubes  are  blocked,  and  they 
contain  pus  or  blood,  removal  gives  the  only  chance  of  relief. 
It  must  not  be  forgotten,  as  an  indication  to  operate,  that  there  is 
real  danger  to  life  in  septic  inflammations  of  the  Fallopian  tubes. 

Hydrosalpinx  is  a  milder  affair,  and  may  be  attended  with 
very  few  symptoms.  In  many  cases  it  is  simply  a  retention 
cyst  in  a  functionally  inert  duct  containing  clear  fluid;  in  others, 
epithelial  debris  or  pus,  sometimes  mixed  with  blood,  is  found. 
The  cause  of  the  occlusion  being  usually  inflammation  extending 
from  the  uterus,  both  tubes  are  often  found  blocked.  In  a  case 
on  which  I  operated,  one  tube  contained  several  ounces  of 
clear  fluid ;  the  other  contained  a  fluid  so  thick  with  flakes  of 
cholesterine,  that  it  looked  like  molten  silver  when  poured  from 
one  vessel  into  another. 

The  diagnosis  is  physical.  A  sausage-shaped  or  tortuous 
cyst  in  the  retro-uterine  space,  with  symptoms  of  disturbed 
sexual  functions,  worst  at  the  periods,  and  less  severe  than 
in  acute  salpingitis,  suggest  the  disease. 

As  to  operation,  hydrosalpinx  is  said — I  believe  on  insufficient 
grounds — sometimes  to  last  a  lifetime,  producing  no  symptoms 
and  causing  no  harm.  In  many  cases  the  symptoms  are  so 
severe  as  to  demand  operation ;  in  all  operation  is  advisable. 
The  disease  will  not  improve ;  from  accidental  or  other  causes 
the  sac  may  suppurate  and  burst,  and  so  endanger  life. 


FALLOPIAN  PREGNANCY.  187 

The  death-rate  in  274  cases  of  operation  for  disease  of  the 
tubes,  collected  by  Schlesinger,  was  found  to  be  8.76  per  cent.  Of 
these,  20  operations  were  said  to  have  been  for  cancer  of  the  tubes 
(note  that  Martin  does  not  mention  a  single  case  of  this  disease); 
115  for  pyosalpinx;  46  for  hydrosalpinx  ;  19  for  haematosalpinx  ; 
43  for  salpingitis ;  7  for  tuberculosis ;  and  23  for  papilloma. 
This  list  must  be  very  far  from  complete  ;  the  operation  has 
been  performed  in  Great  Britain  alone  more  than  400  times.  I 
doubt  also  whether  the  proportions  of  the  varieties  of  diseased 
conditions  would  be  found  to  hold  good  over  a  greater  number 
of  cases.  The  general  mortality  is,  however,  probably  near  the 
truth ;  if  anj^hing,  rather  favourable  than  otherwise.  Special 
mortality  in  the  hands  of  a  few  operators,  covering  nearly  300 
operations,  would  be  found  considerably  under  5  per  cent. 

Fallopian  Pregnancy. — Most  men  are  now  agreed  as  to  the 
truth  of  Tait's  opinion,  that  all  examples  of  extra-uterine  gesta- 
tion are  in  the  beginning  either  wholly  or  partially  Fallopian. 
The  risks  of  rupture  before  the  fourth  month  are  very  great ; 
and  danger  to  life  has  by  no  means  passed  when  the  ovum  is 
killed  by  electricity  or  otherwise. 

I  hold  strongly  to  the  belief  that  as  soon  as  an  extra-uterine 
pregnancy  has  been  diagnosed,  operation  ought  to  be  performed. 
Though  Thomas  and  others  claim  to  have  diagnosed  the  condi- 
tion before  rupture  (and  their  diagnosis  has  in  several  cases 
been  verified  by  subsequent  events,  not  always  favourable 
to  the  patient  however),  it  is  unfortunately  the  case  that  the 
first  sign  of  it  usually  appears  at  rupture,  when  the  woman  is 
dangerously  ill  from  intra-abdominal  bleeding  and  shock.  In 
such  an  event  it  would  be  a  surgical  crime  to  let  the  patient  die 
without  an  attempt  at  relief.  But  under  all  circumstances,  the 
safety  of  the  patient,  immediate  as  well  as  remote,  is  best 
consulted  by  removing  the  ovum  with  the  tube  at  the  earliest 
possible  period.  According  to  Parry,  the  mortality  of  extra- 
uterine pregnancy  is  67.2  per  cent. ;  early  operation  in  com- 
petent hands  would  certainly  give  a  death-rate  of  not  more  than 
5  per  cent.     In  the  hands  of  Tait,  whose  operations  have  all 


188  REMOVAL   OF   THE    UTERINE  APPENDAGES. 

been  at  the  time  of  rupture,  the  mortality  has  been  very  httle 
greater  than  this.  In  America,  where  electricity  is  in  vogue  for 
these  cases,  the  successes  claimed  rest  on  doubtful  diagnoses, 
and  even  then  they  do  not  equal  those  after  operation. 

Conditions  mainly  Uterine. — Of  these,  the  condition  requiring 
operation  most  frequently  is  myoma,  or  uterine  fibroid.  The 
exact  position  of  the  operation  for  uterine  myoma  is  not  yet 
fixed.  It  has  been  much  discussed  and  written  about  at 
meetings  and  in  journals ;  and  the  general  outcome  of  the  dis- 
cussion has  been  that  cause  for  interference  resides,  not  so 
much  in  the  tumour  itself,  its  size  or  situation,  as  upon  the 
symptoms  it  produces. 

Uterine  myoma  has  many  phases.  We  find  it  frequently  in 
post-mortem  examinations  of  patients  who  have  died  of  some- 
thing else,  and  in  whom  it  produced  slight  or  no  symptoms 
during  life.  We  find  it  of  moderate  size  in  young  women,  where 
it  causes  excessive  metrorrhagia,  completely  or  partially  dis- 
abling them.  And  most  frequently  of  all  it  is  met  with  in 
women  near  the  menopause,  as  a  large  slow-growing  mass, 
prolonging  the  periods  and  causing  excessive  flow,  but  not  en- 
dangering life  or  causing  much  disablement.  Lastly,  we  have 
a  class  in  which  the  tumour  goes  on  growing  till  it  reaches 
dimensions  so  great  as  to  interfere  with  the  vital  processes.  The 
rapidly  growing  oedematous  myomata  of  Tait  deserves  special 
mention.  These  groupings  may  be  modified  and  interchanged 
in  numerous  ways ;  they  broadly  represent  the  conditions  as 
most  frequently  met  with,  and  that  is  all. 

It  is  impossible,  without  fully  entering  into  the  whole  ques- 
tion of  the  treatment  of  uterine  myoma,  to  discuss  the  pros  and 
cons  of  removal  of  the  uterine  appendages  for  it.  The  treatment 
has  its  origin  in  a  vera  causa — the  atrophy  of  such  growths  with 
the  natural  atrophy,  at  the  menopause,  of  the  reproductive 
glands.  By  removal  of  the  central  glands  we  seek  to  produce 
atrophy  of  the  organs  whose  functions  are  dependent  on  these 
glands.  The  results  have  been  encouraging,  and  the  operation 
is  received  with  growing  favour.     Even  in  the  hands  of  such 


OPERATION  FOR   MYOMA.  189 

skilled  hysterectomists  as  Keith,  Thornton,  and  Bantock,  re- 
moval of  the  appendages  is  a  favourite  operation.  Tait  has 
always  been  its  chief  advocate  in  this  country. 

The  indications  for  removal  of  the  appendages  cannot  easily 
be  laid  down  in  general  terms.  The  leading  indications  are 
haemorrhage  and  rapidity  of  growth.  Circumstances  of  weight 
are  the  age  and  condition  of  the  patient  and  the  size  of 
the  tumour.  In  large  tumours  it  is  difficult,  and  sometimes 
impossible,  to  remove  the  appendages.  If  the  patient  is  near 
the  menopause,  we  may  temporise,  using  the  ordinary  remedial 
measures  ;  if  the  patient  is  under  thirty-five,  we  must  take  into 
account  the  past  history  of  the  growth  as  to  rapidity  of  enlarge- 
ment and  amount  of  haemorrhage,  and  try  to  forecast  the 
probable  risks  of  leaving  it.  If  the  patient  is  married,  the  risks 
are  increased  from  pregnancy.  If  she  is  in  poor  circumstances, 
forced  to  earn  her  living,  operation  may  be  indicated  ;  while  in  a 
well-to-do  patient,  to  whom  chronic  invalidism  is  not  an  unmiti- 
gated evil,  it  may  not  be  indicated.  With  the  above  reservations, 
free  bleeding,  which  cannot  be  controlled  by  ordinary  means,  is 
the  leading  indication  for  operative  interference.  If  a  growth 
of  small  size  is  growing  rapidly  and  producing  symptoms  of  its 
presence  other  than  bleeding,  and  if  the  woman  is  some  way  off 
the  menopause,  we  may  interfere.  And,  finally,  the  possible 
effects  of  Apostoli's  method  of  appl3'ing  electricity  must  be 
taken  into  account. 

The  general  mortality  of  the  operation  for  myomata  is  some- 
where near  ten  per  cent.  In  the  hands  of  individual  operators 
it  is,  however,  less.  As  to  the  results,  we  may,  in  every  thirteen 
cases  of  recovery  after  operation,  reckon  upon  complete  cure — 
i.e.  shrinking  of  the  tumour  and  menopause — in  ten  cases ; 
improvement  in  two ;  and  failure  in  only  one.  But  these 
results,  with  increasing  care  and  judgment  in  the  selection  of 
cases  and  the  period  of  operation,  will  no  doubt  improve.  If 
cases  of  uterine  myoma  are  kept  under  close  and  constant 
observation,  and  treated  by  removal  of  the  appendages  suffi- 
ciently early,  the  field  of  hysterectomy  for  this  disease  will 
become  greatly  diminished. 


190  REMOVAL   OF  THE   UTERINE  APPENDAGES. 

Certain  congenital  anomalies  and  defects  in  the  uterus,  associated 
with  a  normal  development  of  the  appendages,  may  be  attended 
with  moliminal  disturbances  so  severe  as  to  justify  operation. 
These  are  :  complete  absence  of  the  uterus ;  embryonic,  fcetal 
or  infantile  uterus ;  the  so-called  "  uterus  pubescens."  In  these 
the  menstrual  functions  subsidiary  to  well-developed  tubes  and 
ovaries  cannot  be  properly  discharged.  There  is,  not  retention, 
but  a  complete  absence  or  imperfect  establishment  of  the 
menstrual  flow.  The  uterus  is  overburdened  by  its  ovaries 
and  tubes,  so  to  speak,  and  at  the  periods  of  menstruation  it 
gives  no  relief  to  their  engorgement  by  bleeding.  The  moli- 
minal pains  in  such  cases  are  often  very  severe,  confining  the 
patient  to  bed,  driving  away  sleep,  and  requiring  the  adminis- 
tration of  opium  or  even  chloroform.  In  the  intervals  there 
may  be  comparative  ease  ;  but  frequently  the  pain  spreads  over 
these  intervals  as  well,  and  the  patient  becomes  broken  down 
in  health  and  glides  into  chronic  invalidism.  It  is  often  pos- 
sible in  such  cases  to  detect  the  ovaries  enlarged,  prolapsed, 
and  tender,  and  the  tubes  are  sometimes  abnormally  large 
as  well. 

The  operation  is  sometimes  performed  for  incuvahle  displace- 
ments of  the  uterus  when  the  symptoms  are  severe  and  irremediable. 
Retroversion  and  retroflexion,  where  the  uterus  has  become 
adherent  in  its  abnormal  position,  is  the  most  frequent  con- 
dition. The  uterus  is  enlarged  and  tender,  free  bleeding  takes 
place  at  the  periods,  pessaries  are  either  useless  or  unbearable, 
or  both,  and  other  local  measures,  after  prolonged  trial,  prove 
ineffectual.  The  patient  is  a  chronic  invalid,  probably  confined 
to  bed  or  couch,  and  there  is  no  prospect  of  cure.  In  such  an 
extreme  case  removal  of  the  uterine  appendages,  causing  atrophy 
of  the  uterus,  affords  the  only  chance  of  cure. 

Insuperable  obstruction  to  the  flow  of  the  menstrual  fluid  is  some- 
times an  indication  for  removal  of  the  appendages.  In  such 
cases  there  is  extreme  pain  at  the  periods,  and  sometimes, 
according  to  Battey  and  others,  even  danger  to  life.  Injuries 
during  labour,  such  as  extreme  cicatricial  contraction  of  the 


OPERATION  IN   EPILEPSY.  191 

vagina,  and  destruction  with  occlusion  of  the  lower  part  of  the 
uterus,  are  the  most  frequent  causes.  Congenital  imperforate 
uterus  is  another  cause. 

The  operation  in  mania  has  an  extremely  limited  range. 
The  proposal  of  Goodell  to  remove  the  ovaries  from  all  female 
lunatics  who  have  abnormal  sexual  propensities  cannot  be 
regarded  seriously,  any  more  than  we  should  regard  castration 
under  similar  circumstances  in  the  male.*  Certain  cases  of 
mania,  in  which  the  attacks  come  on  solely  or  chiefly  at  the 
periods,  and  in  which  a  sexual  element  strongly  predominates, 
might,  under  very  special  restrictions,  be  properl}^  treated  by 
removal  of  the  appendages.  In  puerperal  mania,  particularly 
if  the  disease  has  recurred  after  a  second  confinement,  the 
removal  of  portions  of  the  Fallopian  tubes  to  prevent  future 
pregnancy  rather  than  complete  removal  of  the  appendages  is 
indicated.  For  nymphomania  the  position  of  the  operation  is 
less  assured.  The  operation  has  been  performed  for  confirmed 
masturbation ;  but  for  this  purpose  it  does  not  appeal  strongly 
to  the  sympathies  of  t4ie  surgeon.  Indeed,  as  the  operation 
may  not  remove  sexual  feelings,  it  may  not  cure  the  habit. 

In  true  epilepsy,  the  operation  has  not  been  attended  with 
very  favourable  results.  A  few  cases  of  recovery  are  recorded, 
but  the  accounts  of  these  do  not  leave  it  certain  whether  the 
disease  was  true  epilepsy  or  not.  It  is  not  sufficient  to  justify 
operation  that  the  fits  are  worse  or  more  numerous  at  the 
menstrual  periods ;  this  is  true  in  many  examples  of  confirmed 
epilepsy.     Before  operation  is  thought  of,  there  must  be  a  very 

*  Castration  for  madness  in  the  male  has  nevertheless  been  performed. 
Lazarus  Riverius,  "  Counsellor  and  Physitian  to  the  King  of  France,"  in  his 
collected  works  (1678)  quotes,  in  the  following  terse  and  apt  language,  a  case 
communicated  by  one  M .  Samuel  Formius,  "a  most  experienced  chyrurgeon 
of  Montpelier,  having  Practised  the  Art  fifty  years":  "  There  was  a  certain 
young  Man  mad,  and  for  his  Cure  the  most  effectuall  Remedies  were  put  in 
practice,  so  far  as  to  the  use  of  Antimony,  the  Trepan,  and  the  opening  of  the 
Arteries  of  his  Temples.  And  when  all  did  no  good,  I  (Formius)  advised  that 
he  should  be  guelded ;  which  being  done,  all  Symptoms  were  abated,  and  his 
fury  ceased  quite ;  yet  so  that  he  continued  in  melancholy  dotage,  his  madness 
being  changed  into  Melancholy," 


192  REMOVAL   OF   THE    UTERINE  APPENDAGES. 

strong  presumption  that  the  disease  had  its  origin  in  perturbed 
sexual  function,  and  the  disease  must  not  be  so  far  advanced 
as  to  preclude  the  probability  of  cure.  Actual  disease  in  the 
appendages  is  an  indication  for  operation. 

In  hysteyo-epilepsy  there  is,  undoubtedly,  a  fair  and  promising 
field  for  operation.  But  here,  also,  the  mere  existence  of  the 
disease  does  not  indicate  operation.  Clear  and  definite  evidence 
of  its  connection  with  the  sexual  functions  must  be  forthcoming. 
If  the  first  fit  occurred  at  the  first  menstruation ;  if  subsequent 
fits  occurred  exclusively  at  the  periods,  and  if  they  became 
intermenstrual  only  after  having  existed  over  several  years ;  if 
there  is  an  aura  starting  from  the  region  of  the  ovaries;  if  the 
fits  do  not  increase  in  severity ;  if  they  are  unaffected  by  the 
bromides ;  and,  finally  and  most  important  of  all,  if  there  is 
palpable  disease  of  the  appendages,  we  may  consider  the  case 
as  suitable  for  operation.  The  minor  symptoms  of  hystero- 
epilepsy,  such  as  muscular  cramps  and  spasms  and  disturbances 
of  sensation,  are  not  of  importance  surgically.  Of  more  im- 
portance are  the  general  condition  of  the  patient  as  to  health, 
and  her  position  in  life — that  is,  whether  she  must  earn  her  living 
or  not.  If  the  health  is  failing,  and  the  patient  is  becoming  a 
helpless  invalid ;  or  if  she  is  absolutely  precluded  from  sup- 
porting herself  by  her  own  exertions,  and  has  no  future  but 
the  workhouse,  these  we  should  rightly  consider  as  additional 
indications. 

In  not  a  few  of  the  cases  where  cure  has  followed  operation, 
there  has  been  very  slight  or  no  disease  of  the  appendages ;  in 
others,  uterine  stenosis  and  incurable  displacements  are  found. 
The  amount  of  disease  does  not  pari  passu  increase  the  urgency 
of  operation.  Just  as  many  women  whose  sexual  organs  appear 
to  be  perfectly  normal,  and  who  bear  children,  suffer  more  at 
their  periods  than  others  who  are  sterile  from  palpable  disease, 
so  may  a  slight  amount  of  disease  in  one  woman  produce 
hystero-epilepsy,  where  in  another  it  would  produce  no  symp- 
toms whatever.  The  index  of  excitability  to  reflex  neuroses 
varies  in  different  constitutions.  In  a  sliding  scale  downwards, 
it  is  easy  to  reach  the  condition  of  no  local  disease  at  all,  and 


THE  OPERATION.  193 

speak  only  of  disturbed  function  ;  and,  according  to  a  good  few 
reports,  we  must  at  present  accept  this  functional  disturbance 
as  a  real  cause.  But  it  is  only  provisionally  so  accepted  ;  future 
investigations  will  probably  displace  it  altogether. 

For  hysteria  the  operation  has  been  performed,  and  with 
success.  But  operations  of  less  severity  than  removal  of  the 
appendages  have  been  successful  in  hysteria, — a  small  cut  on 
the  abdomen,  for  instance.  For  mere  hysteria,  even  if  accom- 
panied by  "convulsive  attacks"  or  "dancmg  fits,"  few  surgeons 
would  care  to  remove  the  appendages.  The  attacks  would  have 
to  be  very  troublesome  indeed,  and  the  case  would  have  to  be 
surrounded  by  every  conceivable  inducement  to  operate,  before 
interference  could  be  contemplated. 

THE    OPERATION. 

What  will  be  the  exact  nature  and  extent  of  the  operation 
depends  partly  on  the  disease  for  which  the  operation  is  per- 
formed, and  partly  on  the  end  which  the  operator  seeks  to 
secure. 

In  diseases  purely  local  and  one-sided,  such  as  ovarian 
hernia,  single  hydrosalpinx,  simple  ovarian  abscess,  uncompli- 
cated prolapse  of  one  ovary,  and  many  examples  of  Fallopian 
pregnancy,  there  need  be  no  hesitation  in  leaving  the  sound 
organs  untouched.  In  double  h37drosalpinx  without  adhesions, 
the  ovaries  may  be  left  behind.  But  in  all  cases  where  nerve 
disturbances  have  existed  for  some  time,  we  must  reckon  with 
the  force  of  diseased  habit ;  and  here  complete  delivery  from 
pain  may  be  secured  by  nothing  short  of  complete  abrogation  of 
function.  If  a  patient  had  been  suffering  for  years  from  a  small 
abscess  in  one  ovar}',  the  appendages  being  otherwise  normal, 
her  cure  would  almost  certainly  be  more  speedy  and  more 
complete  if  the  whole  of  the  appendages  were  swept  away. 
The  experience  of  Tait"  and  others  is  decidedly  in  favour  of 
bilateral  removal  of  the  organs  for  inflammatory  disease.  After 
26  cases  of  unilateral  removal  for  inflammatory  conditions,  Tait 
found  that  a  second  operation  was  called  for  and  performed  in  4 ; 
*  Birm.  Med.  Rev.,  June,  1887. 
14 


194  REMOVAL   OF  THE    UTERINE    APPENDAGES. 

that  5  cases  of  pyosalpinx  had  subsequently  died,  presumably 
from  rupture  of  abscess  of  the  other  side ;  and  that,  in  7  others, 
a  second  operation  would  be  required.  In  13  out  of  26  cases 
the  unilateral  operation  was  a  complete  failure,  and  complete 
success  could  be  chronicled  for  only  3,  in  the  sense  that  the 
disease  had  not  recurred  on  the  opposite  side.  Each  case  must 
be  judged  on  its  own  merits.  The  duration 'of  the  disease  and 
the  extent"  of  it,  the  age  of  the  patient,  her  position  in  life,  her 
own  and  her  husband's  wishes,  must  all  be  taken  into  account. 

It  happens  in  most  cases  of  inflammatory  disease  that  the 
lesions  are  bilateral ;  and  here  the  question  is  settled  for  us. 
In  those  cases  where  the  motive  is  abrogation  of  function,  or 
cessation  of  uterine  bleeding,  we  have  to  decide  between  simple 
removal  of  the  ovaries — oophorectomy ;  and  removal  of  both 
tubes  and  ovaries — salpingo-oophorectomy. 

Into  a  discussion  of  the  influence  which  the  tubes  ma)' 
possess  over  the  function  of  menstruation  I  cannot  here  enter. 
Suffice  it  to  say,  that  if  Tait's  theories  have  not  everywhere 
been  accepted,  his  practice  has  been  very  generally  followed. 
The  modern  operation  is  removal  of  the  appendages,  and  not 
merel}'  removal  of  the  ovaries. 

Only  practical  considerations  in  support  of  this  practice 
need  be  given  here.     A  few  of  these  are  as  follows  : 

(i)  More  than  one  case  has  been  recorded  in  which  removal 
of  tubes  without  ovaries  has  been  followed  by  menopause.  One 
such  case  has  occurred  in  my  own  practice.  In  this  case 
menopause  was  not  sought.  On  the  other  hand,  many  cases  of 
double  oophorectomy  have  not  been  followed  by  complete  change 
of  life.  The  best  results  published  so  far  have  been  got  from 
complete  removal  of  the  appendages. 

(2)  A  better  pedicle  is  afforded  for  deligation  when  both 
tubes  and  ovaries  are  included.  A  ligature  surrounding  the 
ovarian  attachments  alone  is  liable  to  cause  kinking  of  the  tube 
with  subsequent  risk  of  occlusion  or  distension.  The  hilum  of 
the  ovar}',  with  its  plexus  of  vessels,  is  not  satisfactory  tissue 
for  inclusion  in  ligature. 

(3)  By  removal  of  the  tubes,  all  further  risks  of  disease  in 


THE   OPERATION.  195 

them  are  done  away  with.  The  ovaries  can  scarcely  be 
removed  without  upsetting  the  blood  supply  to  the  tubes, 
and  causing  some  physical  injury  to  them  as  well.  Venous 
congestion  or  actual  inflammation  in  the  tubes  might  readily 
follow  simple  oophorectomy,  and  nullify  the  benefits  of  the 
operation. 

(4)  The  tubes  are  useless  when  the  ovaries  are  removed.  If 
one  good  reason  for  their  removal  can  be  given,  and  none  for 
their  being  left  behind,  the  question  at  issue  is  settled. 

Removal  of  the  uterine  appendages  may  be  either  a  very 
simple  or  a  very  difficult  proceeding.  If  the  organs  occupy 
their  normal  situations  and  there  are  no  adhesions,  as  in  the 
cases  to  which  the  term  castration  may  with  least  impropriety 
be  applied,  for  small  bleeding  myomata,  or  absent  or  malformed 
uterus,  or  cystic  ovaries,  or  such  like,  the  operation  is  easy.  If, 
as  in  inflammatory  disease,  they  are  displaced  and  matted 
together  and  to  the  surrounding  organs,  the  operation  may  be 
one  of  great  difficulty  and  delicacy.  For  large  myomata,  again, 
the  operation  presents  special  features  which  may  cause  diffi- 
culties ;  and  finally,  the  proceeding  in  the  case  of  ovarian 
hernia  is  peculiar  to  itself. 

Where  the  Appendages  are  Anatomically  Normal,  or  nearly  so. — The 
incision,  made  in  the  ordinary  median  position  between  the 
umbilicus  and  pubes,  need  not  be  longer  than  an  inch  and  a 
half  or  two  inches — enough  easily  to  admit  two  fingers.  At  the 
second  or  third  cut  the  fibres  of  the  linea  alba  are  laid  bare 
through  the  whole  length  of  the  wound.  Pressure  forceps  are 
placed  on  any  bleeding  points,  and  left  attached.  As  the 
parietes  are  not  thinned  and  distended  by  a  tumour,  the  linea 
alba  is  very  narrow,  and  it  is  not  often  that  it  can  be  divided 
without  exposing  one  or  both  recti.  A  small  opening  is  made 
in  the  fascia :  if  it  is  in  the  linea  alba,  well  and  good  ;  if  not, 
the  layers  are  pushed  to  one  side  or  the  other,  and  when  the 
situation  of  the  fibrous  septum  is  found,  the  fascia  is  slit  up  to 
the  length  of  the  wound  by  the  point  of  the  knife  cutting  for- 
wards.    The  muscular  fibres  are  pushed  to  one  side  with  the 

14  * 


196  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

handle  of  the  scalpel,  and  the  sub-peritoneal  fat  exposed.  This 
is  caught  up  on  two  catch  forceps,  and  carefully  divided  between 
them  ;  and  the  rest  of  the  division  is  made  while  the  tissues  are 
pulled  out  of  the  wound.  The  peritoneum  is  easily  recognised  : 
a  small  opening  is  made  in  it  while  it  is  thus  everted;  the  finger 
inserted  into  this  opening  acts  as  a  director  upon  which  the 
division  is  completed,  preferably  by  scissors.  B}^  this  method 
there  is  no  danger  in  wounding  bowels  :  as  each  fold  of  tissue  is 
pulled  up  and  made  tense,  it  is  cut  on  its  folded  edge  by  the 
blade  of  the  knife,  held  horizontally;  and  when  the  ver}'  smallest 
opening  has  been  made  in  the  peritoneum  the  air  rushes  in,  and 
the  bowels,  if  they  have  been  dragged  forward  by  suction, 
fall  back  at  once.  With  moderate  care,  there  is  not  the 
slightest  danger  of  wounding  bowel :  it  is  idle  to  use  it  as  an 
argument  against  the  operation,  as  one  distinguished  gynae- 
cologist has  done,  that  there  is  great  danger  of  wounding  the 
intestine. 

The  first  two  fingers  are  now  inserted  into  the  wound.  If 
omentum  covers  the  bowels,  it  must  be  dragged  upwards  ;  if 
not,  the  fingers  are  pushed  straight  down  to  the  fundus  uteri. 
The  fingers,  one  on  each  side  of  the  broad  ligament,  and  grasp- 
ing it  between  them,  are  now  carried  outwards  till  the  ovary  is 
felt ;  it  is  then  lifted  out  of  the  wound,  with  its  mesovarium  and 
its  oviduct.  Still  held  in  this  position  in  the  left  hand,  the 
Fallopian  tube  is  pulled  out  as  far  as  it  will  readily  come,  and 
the  pedicle  spread  out  for  ligature.  The  parts  to  be  removed 
are  the  ovary  with  its  mesovarium,  and  the  Fallopian  tube  in 
its  outer  three-fourths,  with  the  double  peritoneal  fold  in  which 
it  lies,  and  which  contains  also  the  parovarium  and  the  vascular 
erectile  tissue  known  as  the  bulb  of  the  ovary.  The  ligature  is 
placed  double  by  transfixing  with  a  blunt  needle.  The  inner 
pedicle  contains  the  utero-ovarian  ligament,  the  Fallopian  tube 
somewhere  near  its  isthmus,  the  spermatic  artery  and  its  veins, 
and  the  small  branch  which  accompanies  the  Fallopian  tube. 
The  outer  ligature  lies  at  the  retiring  angle  where  the  infun- 
dibulo-pelvic  and  infundibulo-ovarian  ligaments  meet,  takes  its 
half  of  the  mesovarium,  and  also  constricts  the  spermatic  artery. 


THE  OPERATION.  197 

In  most  cases  no  method  of  ligature  is,  in  my  opinion,  superior 
to  Tait's  Staffordshire  knot.  The  loop  carried  through  by  the 
needle  (which  must  be  very  blunt,  to  prevent  the  accident  of 
wounding  any  of  the  numerous  small  veins)  is  caught  by  a  finger 
and  the  needle  withdrawn.  The  loop  is  then  raised  over  the 
parts  to  be  removed,  and  one  of  the  free  ends  drawn  through 
the  loop  and  over  it.  The  free  ends  are  now  caught  in  one 
hand  and  pulled  tight,  while  the  fingers  and  thumb  of  the  other 
hand  act  as  an  opposing  force  at  the  site  of  delegation.  The 
knot  is  then  cast  and  tied  tightly,  either  by  the  operator  unaided, 
or  with  the  help  of  the  assistant,  who  pulls  on  one  end  of  the 
ligature.  The  parts  are  then  cut  away,  b}^  successive  snips  of 
scissors,  at  a  distance  of  about  a  third  of  an  inch  from  the 
ligature.  Before  making  the  last  cut  the  surface  must  be  care- 
fully inspected,  to  see  that  there  is  no  bleeding.  The  pedicle  is 
then  dropped  in.  A  more  deliberate,  and  perhaps  more  clumsy, 
plan  is,  to  catch  the  sides  of  the  pedicle  in  fixation  forceps,  hand 
these  over  to  an  assistant,  and  apply  the  ligature  below  them. 
The  same  proceeding  is  then  carried  out  with  the  appendages 
on  the  opposite  side. 

A  small,  thin,  flat  sponge  is  now  placed  over  the  bowels 
under  the  incision ;  and  the  sutures,  four  or  five  in  number,  are 
introduced. 

When  the  Appendages  are  Inflamed,  and  Adherent. — The  previous 
operation  is  a  very  simple  one.  From  first  to  last,  in  competent 
hands,  it  can  scarcely  occupy  more  than  ten  minutes.  But  it 
is  a  very  different  thing  if  the  appendages  are  adherent  or 
inflamed,  or  suppurating  and  matted  together.  Then  the 
operation  may  be  one  of  the  most  difficult  in  surger}'.  Even  in 
tlie  hands  of  surgeons  of  the  highest  skill,  it  has  not  infrequently 
been  abandoned  as  impracticable. 

The  first  difficulty  met  with  is,  probably,  that  the  appendages 
are  fixed  and  cannot  be  drawn  to  the  surface.  They  may  be 
represented  by  an  irregular  conglomeration  of  cystic  and  cica- 
tricial material,  sessile  on  the  broad  ligament  or  in  Douglas's 
pouch,  and  perhaps  intimately  adherent  to  bowels.     They  are 


198  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

beyond  the  reach  of  sight,  however  much  the  abdominal  walls 
are  depressed.  To  deal  with  such  a  state  of  affairs,  one  of  two 
courses  is  open.  The  first  is  to  enlarge  the  incision  to  five  or 
six  inches ;  to  pull  the  bowels  out  of  the  pelvis  and  keep  them 
in  the  abdomen  by  one  or  more  sponges  packed  under  them  ;  to 
pull  the  parietes  apart  by  spatulge,  and  seek  by  a  strong  light  to 
expose  the  parts  to  view,  and  operate  by  the  aid  of  sight. 
This  may  be  safe,  but  it  is  clumsy  and  difficult.  If  the  parietes 
are  muscular  and  firm,  considerable  force  may  be  required  to 
crowd  the  bowels  into  the  abdomen,  and  to  keep  them  there  is 
still  more  difficult.  And  it  is  not  easy  at  the  bottom  of  the 
pelvis  to  perform  delicate  surgical  manipulations  with  knife  or 
scissors  and  ligature.  Several  operators  have  had  recourse  to 
the  doubtful  expedient  of  making  space  by  turning  the  bowels 
outside  the  abdomen  altogether. 

The  other  course  is  that  followed  by  Tait.  As  a  result  of  his 
unrivalled  experience,  Tait  has  come  to  the  conclusion  that  it  is 
best  to  depend  entirely  on  the  fingers  to  deal  with  such  a  con- 
dition, relying  on  the  skilled  sense  of  touch  to  guide  against  the 
dangers  of  tearing  bowel  or  other  structures.  To  control  bleed- 
ing he  recommends  sponge-packing.  Firstly,  the  fingers  map 
out  the  actual  limits  of  the  diseased  organs ;  then  these  are 
gently  separated  from  all  surrounding  organs,  and  gradually  the 
mass  is  unfolded  upwards  fromb)ehind  till  the  onl)^  attachment 
left  is  the  proper  pedicle  of  the  parts  to  be  removed.  Even  as 
thus  separated  the  appendages  will  probably  be  found  sessile  on 
the  broad  ligament,  so  that  they  can  be  little  more  than  brought 
within  the  range  of  sight.  The  broad  ligaments  are  stretched 
tightly  across  the  pelvis,  and  dragging  on  the  appendages  may 
tear  them.  The  pedicle  ligature  may  have  to  be  carried  under 
the  diseased  parts  at  a  considerable  depth  from  the  surface. 
If  possible,  all  the  tissues  are  gathered  together  in  one  pedicle, 
as  by  the  Staffordshire  knot ;  but  the  puckering  so  produced 
may  drag  upon  the  opposite  ligamemt  to  such  an  extent  as  to 
cause  tearing.  To  tie  in  two  parts  almost  of  necessity  tears 
open  the  tissue  between  them.  It  has  happened  to  me  in  one 
case,  while  putting  on  a  ligature,  that  the  broad  hgament  was 


THE  OPERATION.  199 

torn  clean  away  from  the  side  of  the  uterus  for  a  distance  of 
more  than  an  inch. 

In  dealing  with  such  a  difficulty,  Tait,  always  fertile  in 
expedients,  tells  me  that  he  is  in  the  habit  of  pushing  his 
finger  down  on  the  broad  ligament,  close  to  the  pelvic  insertion 
of  it,  and  so  causing  a  series  of  minute  tears  through  the  fibrous 
fasciae  and  peritoneum,  but  leaving  the  elastic,  distensile,  and 
tortuous  vessels  uninjured. 

I  have  thought  that  an  air  bag  inflated  in  the  rectum  might 
sometimes  be  of  use  by  raising  the  whole  pelvic  floor. 

The  bleeding  in  these  cases  is  sometimes  described  as  being 
truly  alarming,  and  I  have  had  practical  experience  of  this 
fact.  Sponges  are  packed  in  everywhere  as  the  adhesions  are 
separated,  and  as  the  haemorrhage  is  started.  If,  after  the 
appendages  have  been  removed,  bleeding  still  goes  on,  a  little 
solution  of  iodine  on  a  sponge  may  be  applied  to  the  raw 
surfaces.  Of  course  visible  bleeding  points  are  dealt  with  by 
ligature  or  forci-pressure.  And  it  may  sometimes  be  good 
practice  to  leave  forceps  attached  to  bleeding  points  for  twenty- 
four  hours  or  so,  their  handles  being  left  outside.  In  all  such 
cases  the  insertion  of  a  glass  drainage-tube  for  a  day  or  two  is 
advisable. 

During  the  performance  of  these  operations  we  must  bear 
in  mind  the  fact  that  adhesions  between  intestines  may  cause 
great  pain.  If  it  is  possible  to  separate  such  adhesions 
without  endangering  the  intestinal  walls,  the  intestines  should 
be  set  free.  The  separation  must  be  done  with  great  care 
delicacy,  and  always,  if  possible,  within  the  range  of  sight. 

If  an  abscess  or  abscesses  exist,  extra  care  is  necessary 
to  avoid  rupture  of  the  abscess  wall.  It  will  be  wise  before 
beginning  separation  to  aspirate  the  contents,  and  place  a 
pressure  forceps  on  the  opening  so  made.  In  such  cases  the 
placing  of  sponges  all  round  the  diseased  parts  is  peculiarly 
necessary. 

•    For    Uterine   Myoma. — For   small   myomata   the    proceeding 
juay  be  in  no  way  different  from    the  simplest  operation.     In 


200  REMOVAL   OF  THE    UTERINE  APPENDAGES. 

fact,  as  the  appendages  are  raised  with  the  fundus,  and  the 
broad  hgaments  are  usually  soft  and  distensile,  the  operation 
may  be  rendered  easier. 

When  the  tumour  is  large,  and  especially  when  it  is 
adherent,  the  difficulties  may  be  great,  even  insuperable.  Not 
a  few  such  operations,  begun  as  oophorectomy,  have  had  to  be 
finished  as  hysterectomy.  If  the  tumour  grows  away  from  the 
uterus,  being  sub-peritoneal  and  near  the  fundus,  the  append- 
ages ma}^  be  deep  in  the  pelvis.  Where  the  growth  lies  between 
the  broad  ligaments  the  ovaries  will  be  elevated,  and  squeezed 
between  the  tumour  and  the  parietes.  In  an  unsymmetrical 
growth  one  ovary  may  be  quite  conveniently  near  the  surface, 
while  the  other  lies  out  of  reach  and  behind.  Indeed,  we  must 
expect  an  endless  variety  of  situation,  and  in  some  cases  be 
prepared  not  to  find  ovaries  at  all. 

When  one  ovary  is  found,  we  must,  before  proceeding  to 
remove  it,  find  the  other  :  and  before  removing  one  we  must  be 
certain  that  it  is  possible  to  remove  both.  Having  decided  to 
remove  the  appendages,  we  rotate  the  tumour  to  one  side,  so  as 
to  bring  the  parts  first  to  be  removed  as  close  as  possible  to 
the  surface.  The  pedicle  is  secured  in  the  ordinary  way  by  a 
Staffordshire  knot,  or  in  any  other  way  that  seems  suitable  for 
the  case.  Thornton's  plan,  of  not  cutting  off"  the  first  ovary  till 
all  manipulations  are  over  with  the  second,  is  a  good  one :  it 
minimises  the  risk  of  bleeding  from  the  divided  pedicle. 
Forceps  are  left  attached  to  the  appendages  first  ligated : 
the  appendages  on  the  other  side  are  brought  as  near  to  the 
surface  as  possible  by  rotating  the  growth,  tied,  cut  off",  and 
covered  with  a  flat  sponge.  The  appendages  on  the  other 
side  are  then  cut  off",  and  also  covered  with  a  sponge.  When 
the  sutures  have  been  inserted  in  the  parietal  wound,  the 
sponges  are  removed  and  the  wound  closed. 

For  Ovarian  Hernia. — When,  from  pain  or  symptoms  of 
strangulation,  it  has  become  necessary  to  operate  upon  an 
ovarian  hernia,  it  is  usually  found  the  best  surgery  to  remove 
the  herniated  parts.     The  incisions  are  made  as  for  ordinary 


PROGRESS  OF  THE   OPERATION.  201 

hernia,  and  the  appendages  are  removed  according  to  the 
principles  laid  down.  Mr.  Lawson  advises  that  the  divided 
end  of  the  Fallopian  tube  be  fixed  in  the  wound  by  a  suture : 
this  procedure  seems  to  be  no  more  necessary  in  operating  here 
than  by  abdominal  section.  In  most  cases  there  will  be  found 
adhesions  fixing  the  herniated  organs  in  the  sac.  Hulke  has 
operated  upon  a  case  in  which  one  cornu  of  a  bifid  uterus  lay 
in  the  sac  with  the  appendages,  and  "  the  inguinal  portion  of 
the  uterus  was  invested  by  peritoneum,  which  passed  directly 
into  that  of  the  hernial  sac,  and  thus  fixed  the  organ  in  situ." 
In  herniated  ovaries  which  are  easily  reducible  there  is  danger  of 
their  slipping  into  the  abdomen  during  operation;  to  avoid  the 
risk  of  this,  it  is  suggested  that  a  needle  be  passed  behind  the 
ovary  to  fix  it — a  proceeding  which  is  open  to  the  objection  that 
bowel  may  be  pierced.  In  some  cases,  where  the  hernia  only 
occasionally  takes  place,  it  may  be  most  expedient  to  remove 
the  appendages  by  abdominal  section. 

Ligature  instead  of  Removal. — In  cases  where  removal  is- 
extremely  difficult,  or  impossible,  the  proposal  of  Professor 
Simpson,  to  strangulate  the  blood  supply  by  ligation,  is  worthy 
of  a  trial.  In  his  hands,  and  in  the  hands  of  Leopold  of 
Leipzig,  and  others,  it  has  done  good.  Dr.  Geza  v.  Antal,  of 
Buda-Pest,"  urges  atrophic  ligature  of  the  ovaries,  not  only  for 
uterine  fibroids,  but  for  uterine  versions  or  flexions,  ovarian 
displacements  and  other  conditions.  More  than  one  writer  has 
suggested  that  the  whole  proceeding  of  removal  of  the  ap- 
pendages does  good  entirely  by  cutting  off  blood-supply. 

Removal  by  the  Vagina  has  now  practically  been  abandoned, 
and  need  not  be  described.  I  have  once  operated  in  this  way 
with  success. 

PROGRESS  AFTER  OPERATION. 

The  progress  immediately  after  operation  in  all  essential 
particulars  so  closely  resembles  that  seen  after  ordinary  ovari- 
otomy, that  it  need  not  be  described.  Two  peculiarities  may  be 
mentioned — pain  and  uterine  haemorrhage. 

*  CentralbL  f.  Gyndk.,  1882,  No.  30. 


*i02  REMOVAL   OF   THE    UTERINE  APPENDAGES. 

After  removal  of  the  appendages  there  is  usually,  for  a  day 
or  two,  considerable  pain  in  the  hypogastrium,  far  more  than  is 
seen  after  removal  of  cystomata.  We  ought  to  be  chary  of 
having  recourse  at  once  to  opium.  Flatulence  and  sickness  are 
such  frequent  sequences  of  opiates,  however  administered,  that 
it  is  always  wise  to  postpone  their  administration  up  to  the  limits 
of  the  patient's  endurance.  The  pain  soon  passes  off;  it  rarely 
continues  over  the  second  day.  Battey  used  to  divide  the  pedicle 
by  ecraseur,  to  try  and  do  away  with  this  pain ;  statements  as  to 
the  success  of  his  practice  are  not  published.  If  there  is  rest- 
lessness or  jactitation,  opium  is  specially  indicated. 

On  the  second,  third,  or  fourth  day  after  operation  we  may 
expect  bleeding  from  the  uterus  to  take  place.  The  bleeding  is 
usually  considerable  in  amount,  and  may  continue  over  four  or 
five  days.  It  is  in  no  way  harmful ;  indeed,  it  is  usually  ac- 
companied by  amelioration  of  the  subjective  symptoms.  Some 
surgeons  consider  it  part  of  the  cure  in  the  operation  for  myoma. 
It  requires  no  treatment,  and  need  cause  no  anxiety. 

Remote  Effects  of  the  Operation. — The  individual  results  of  the 
operation  as  performed  for  specific  disease  have  already  been 
described,  and  the  general  results  so  far  as  they  affect  the 
feminine  attributes  have  been  sufficiently  discussed.  It  remains 
shortly  to  give  an  account  of  the  behaviour  of  cases,  with  par- 
ticular reference  to  the  uterine  functions  and  with  general 
reference  to  bodily  health  as  observed  for  a  year  or  more  after 
operation.  Each  disease  has  its  own  record,  and  all  diseases 
have  points  in  common. 

For  inflammatory  disease,  which  is  perhaps  the  most  satis- 
factory source  of  operation,  the  record  is  broadly  as  follows: — 
At  the  end  of  a  fortnight  or  three  weeks  the  patient  will  probably 
express  herself  as  feeling  peculiarly  well,  and  will  be  anxious  to 
get  up.  When  she  has  been  getting  about  for  a  week  or  so,  and 
at  the  time  when  menstruation  is  due,  she  will  probably  complain 
of  backache  and  feelings  of  weight  in  the  hypogastrium,  and  pos- 
sibly her  spirits  may  become  a  little  depressed.  Most  probably 
there  will  be  molimina,  but  no  menstrual  flow.  During  the  next 
month  slight  backache,  with  some  general  weakness,  may  be 


EFFECTS   OF   THE   OPERATION.  203 

complained  of;  and  somewhere  near  the  next  period  these 
symptoms  may  be  aggravated.  These  cases  do  not  get  quite 
well  very  quickly  as  a  rule  ;  and  this,  of  course,  is  not  to  be 
expected,  considering  their  previous  prolonged  illness.  In 
from  three  to  six  months  perfect  recovery  may  be  expected. 
But  all  the  old  pain  will  have  disappeared;  and  this  alone,  even 
in  the  most  tedious  cases,  the  patient  will  say  was  more  than 
enough  to  justify  operation.  Regular  menstruation  is  very  rare, 
irregular  and  slight  bleedings  are  more  common;  neither  is 
likely  to  continue  over  more  than  six  months.  In  a  considerable 
majority  amenorrhoea,  immediate  and  permanent,  follows  the 
metrorrhagia  which  occurs  a  few  days  after  operation. 

In  myoma  the  result  is  very  variable  as  to  subsequent  course. 
There  occurs  the  ordinary  metrorrhagia  immediately  after 
operation.  Thereafter  we  may  expect  complete  arrest  of  men- 
struation, with,  at  first,  cessation  in  the  growth  of  the  tumour, 
and  then  slow  but  steady  diminution  in  size.  This  shrinking  is  by 
no  means  confined  to  small  tumours,  and  it  is  rarely  possible  to 
tell  what  tumours  will  shrink  and  what  will  not  shrink. 

There  is  one  variety  of  myoma — the  soft,  cedematous — 
which,  Tait  tells  us,  goes  on  growing  after  removal  of  the 
appendages,  and  which  can  be  treated  only  by  hysterectomy.  I 
can  find  no  definite  information  as  to  the  utility  of  removal  of  the 
appendages  after  the  period  of  the  menopause  has  passed ;  and 
it  would  be  dangerous,  considering  how  little  we  really  know  of 
their  functions  even  when  supposed  to  be  physiologically  inert, 
to  speculate  as  to  the  possible  benefits  to  be  derived  from  the 
proceeding.  A  tumour  may  not  show  signs  of  diminution  in 
size  for  several  months,  when  it  may  begin  to  decrease  in  bulk 
over  one  or  two  years,  and  then  reach  dimensions  which  are 
stationary. 

For  the  neuroses,  the  results  are  at  once  highly  encouraging 
and  deeply  disappointing.  The  balance,  however,  lies  largely  on 
the  side  of  encouragement.  The  failures  have  been  chiefly  in  cases 
of  epilepsy  ;  and  here,  no  doubt,  errors  arising  from  an  improper 
selection  of  cases  have  been  most  numerous.  In  favourable  cases 
we  are  not  to  expect  complete  and  perfect  cure  from  the  beginning. 


204  REMOVAL   OF  THE    UTERINE   APPENDAGES. 

For  the  first  few  weeks  there  may  be  a  complete  cessation  of  the 
abnormal  nerve- phenomena  ;  at  the  time  of  the  next  period  there 
may  be  a  few  fits ;  then  in  diminishing  numbers  a  few  more  fits, 
lasting  over  several  months.  Perfect  recovery  must  not  be 
counted  upon  within  six  months  at  least ;  and  this  recovery  must 
be  encouraged  by  strict  attention  to  regimen  and  surroundings. 

Battey,  at  the  twelfth  annual  meeting  of  the  American 
Gynsecologists,  held  in  New  York,  September  15th,  1887,  read  a 
paper  on  the  matured  results  of  54  cases  operated  upon  by  him. 
His  conclusions  seem  to  fairly  and  clearly  state  the  experience 
of  others.     He  says  : — 

(i)  That  the  change  of  life  is  the  most  important  factor  in 
securing  the  complete  result  of  the  operation, 

(2)  That  only  in  exceptional  cases  did  cure  immediately 
follow  operation  ;  in  the  vast  majority  the  patient  had  to  pass 
through  the  ups  and  downs  incident  to  the  change  of  life  before 
the  restoration  to  health  was  complete.  This  period  lasted  from 
one  to  five  years. 

(3)  Very  long  standing  cases  reach  a  stage  when  they  become 
absolutely  incurable  by  any  operation. 

(4)  In  some  cases  which  seemed  suitable  for  operation  the 
pain  continued ;  and  his  experience  has  not  yet  taught  him  how 
perfectly  to  select  the  cases. 


Section    IV. 


OPERATIONS   ON   THE   NON-GRAVID    UTERUS. 


In  this  section  we  have  to  consider  removal  of  the  uterus  for 
malignant  disease,  for  incurable  inversion,  and  for  myoma.  For 
malignant  disease,  removal  by  the  vagina — Kolpo-hysterectomy — 
is  the  operation  described ;  it  means  complete  excision  of  the 
vi^hole  organ.  For  incurable  inversion,  removal  may  or  may  not 
be  complete.  For  myoma  the  operation  is  in  the  first  place  a 
myomectomy  ;  in  most  cases,  however,  it  is  also  a  hysterectomy, 
total  or  partial.  The  operations  are  usually  named  according 
to  the  purpose  for  which  they  are  performed — Hysterectomy 
for  malignant  disease,  for  inversion,  and  for  myoma. 

SURGICAL  ANATOMY  OF  THE  UTERUS. 

The  relational  anatomy  of  the  uterus  is  of  extreme  practical 
importance.  It  is  chiefly  the  close  contiguity  of  bladder,  ureters, 
and  other  impo  rtant  structures  which  renders  removal  of  the 


206 


OPERATIONS  ON   THE    UTERUS. 


uterus  such  a  difficult  and  delicate  proceeding.  No  surgeon 
ought  to  attempt  the  operation  of  hysterectomy  who  has 
not  previously  made  himself  familiar,  by  study,  dissection,  and 

operation  on  the  cadaver,  with  every 
anatomical  and  technical  detail. 

The  ligaments  of  the  uterus  have 
already  been  sufficiently  described  ; 
here  we  have  specially  to  consider 
its  vascular  supply,  and  its  relations 
to  bladder,  ureters,  rectum,  and  peri- 
toneum. 

Over  the  fundus  uteri  the  peri- 
toneum is  closely  adherent.  In  the 
front,  as  it  descends  to  the  junction 
of  the  body  and  the  cervix,  it  is  less 
intimately  attached  to  the  muscular 
tissue ;  and,  at  the  bottom  of  the 
vesico-uterine  depression,  it  is  so 
loosely  attached  that  it  can  readily 
be  stripped  with  the  finger.  Here  is 
the  most  important  surgical  region. 
The  reflection  of  peritoneum  from 
uterus  to  bladder  is  usually  at  the 
level  of  the  internal  os,  but  it  is 
liable  to  be  elevated  or  depressed. 
(Fig,  31.)  In  children  it  is  higher 
up,  in  multiparae  and  old  women  it 
is  lower  down,  than  the  average 
level.  In  close  relation  with  the 
under  surface  of  the  vesico-uterine 


Fig.  31. 

Vertical  antero-posterior  section  of 
the  uterus.     (Courty.) 

2,  isthmus  separating  the  cavity  of 
the  body  from  that  of  the  cervix  ;  a, 
anterior  lip  of  the  cervix ;  p,  poste- 
rior lip  ;  /,  posterior  vagino-uterine 
cul-de-sac ;  va,  va,  vagina ;  b,  b,  con- 
nections of  the  urinary  bladder  with 
the  anterior  surface  ot  the  cervix  ;  r, 
reflection  of  the  peritoneum  from  the 
posterior  surface  of  the  uterus  and 
vagina  to  the  rectum  ; 


commence- 
ment  of  the  utero-lumbar  suspensory      pQ^^h    lie    the    baSC    of   the    bladder, 
ligaments.  i^ 

and  the  ureters  imbedded  in  cellular 
tissue.  The  bladder  wall,  for  a  distance  of  fourteen  millimetres, 
lies  on  the  cervix  uteri ;  below  this,  as  far  as  the  pubes,  it  rests 
on  the  vagina.  Courty  found,  as  the  result  of  a  great  number  of 
measurements  taken  at  all  ages,  that  the  distance  between  the 
opening  of  the  ureter  into  the  bladder  and  the  insertion  of  the 


SURGICAL   ANATOMY.  207 

vagina  into  the  cervix  was  on  an  average  between  one  and  two 
centimetres  in  length.  The  distance  between  the  margin  of  the 
uterus  and  the  ureter  varies  according  to  the  size  of  the  cervix, 
and  also  according  to  the  condition  of  the  bladder  as  to  empti- 
ness or  distension.  With  an  empty  bladder  and  a  normal  uterus 
a  distance  of  quite  half  an  inch  may  be  reckoned  upon  as 
separating  the  cervix  from  the  insertion  of  the  ureter  into  the 
bladder  wall. 

The  peritoneum  covering  the  posterior  surface  of  the  uterus 
is  continued  over  the  utero-sacral  ligaments,  and  carried  down 
for  about  three-quarters  of  an  inch  over  the  posterior  vaginal 
wall,  when  it  is  reflected  up  the  rectum,  forming  Douglas's  pouch. 
Though  the  sub-peritoneal  cellular  tissue  is  not  so  abundant 
behind  as  in  front,  the  peritoneum  can  be  readily  peeled  off  as 
high  as  the  level  of  the  internal  os. 

The  cellular  tissue  lying  between  the  folds  of  the  broad 
ligament  is  continuous  below  with  that  which  ascends  in  front 
over  the  lateral  surfaces  of  the  bladder  up  to  the  hyppgastrium, 
and  that  which  descends  behind  over  the  levator  ani  and  upper 
perineal  aponeuroses.  In  this  cellular  tissue  course  the  uterine 
vessels  and  the  ureters. 

The  uterine  artery,  a  branch  of  the  anterior  trunk  of  the 
internal  iliac,  passes  obliquely  downwards  and  forwards  from  its 
origin  near  the  synchondrosis  towards  the  spine  of  the  ischium. 
Just  above  the  ischial  spine  it  leaves  the  pelvic  wall,  but  con- 
tinuues  to  descend  half-way  to  the  tuberosity  of  the  ischium, 
where  it  turns  upwards,  bending  towards  the  vagina  to  which  it 
gives  branches,  and  reaching  the  uterus  at  its  junction  with  the 
vagina.  It  runs  up  the  side  of  the  uterus  between  the  folds  of 
the  broad  ligaments,  supplying  the  organ  with  vessels,  and  finall}^ 
anastomoses  with  the  ovarian  artery  near  the  cornu.  (Fig.  32.) 
Opposite  the  external  os  the  uterine  artery  gives  off  a  consider- 
able branch,  the  circular  artery  of  the  cervix,  and  it  gives  off 
other  branches  in  its  course  upwards.  Throughout  its  course  the 
vessel  is  tortuous  and  loosely  supported  by  cellular  tissue.  At  its 
lowest  point  it  is  on  a  level  with  the  external  os,  and  here  it 
passes  directly  over  the  ureter,  almost  in  contact  with  it,  but  not 


208 


OPERATIONS  ON   THE    UTERUS. 


at  all  attached.     The  lateral  branches  given  off  to  the  uterus  by 
the   uterine    artery    are    so   numerous   that    local   compression 
from  flexions  or  other  causes  can  scarcely  render  any  part  of 
the  organ 
ansemic. 

The  ova- 
rian or  sper- 
matic ar- 
teries arise 
from  the 
aorta  be- 
low the 
level  of  the 
renal  ar- 
teries, and 
cross  the 
pelvic  brim 
at,  or  in 
front  of,  the 
bifurcation 
of  the  com- 
mon iliac, 
crossing 
the  ureter, 
and  run- 
ning along 
the  upper 
border  of 
the  broad 
ligament  to 
the  cornu. 
More  ex- 
actly, they 
may  be  said 


Fig.  32. 

Drawing  from  a  dissection  made  to  show  relations  of  ureters, 
uterine  arteries,  bladder,  &-c. 

nr.,  ureter  ;  nt.Ar.,  uterine  artery  ;  o.ti.,  os  uteri  exposed  by  an  incision, 
X,  made  through  the  top  of  the  vagina  ;  bl.,  bladder,  the  walls  of  which  are 
cut  away  down  to  the  insertion  of  the  ureters  into  its  base  ;  Vag.,  vagina. 
Two  bands  of  fibrous  tissue  are  seen  passing  between  the  cervix  uteri 
and  the  top  of  the  vagina.  Arterial  branches  of  considerable  magnitude 
accompany  the  ureters.  The  space  between  the  bladder  wall  and  the 
unshaded  body  of  the  uterus  (artificially  enlarged  by  traction  of  hook)  is 
covered  by  peritoneum,  in  the  loose  cellular  tissue  underlying  which  the 
bladder  wall  rises  upwards  to  a  varying  distance. 


to  lie  between  the  folds  of  the  infundibulo-pelvic  ligament.  In 
the  round  ligament  is  a  branch  from  the  epigastric  artery  which 
reaches  the  uterus. 


SURGICAL   ANATOMY.  209 

Although  the  uterine  artery  is  usually  larger  than  the  ovarian, 
the  reverse  is  occasionally  the  case.  Their  relative  dimensions 
are  liable  to  endless  variation. 

The  relations  of  the  ureters  to  the  uterus  are  of  prime 
importance.  The  researches  of  Holl  of  Innsbruck, *  Garrigues 
(quoted  by  Hart  and  Barbour)  and  Polk,f  painstaking  and 
thorough  as  they  are,  by  no  means  agree.  Mr.  J.  Collier  and 
Prof.  Morrison  Watson,  quoted  by  Dr.  Thorburn,|  have  given 
a  description  of  the  course  of  the  ureters,  which  I  have  several 
times  verified  by  dissection,  and  which,  I  think,  may  be  trusted. 
Entering  the  pelvis,  the  ureter  crosses  the  common  iliac  near  its 
bifurcation,  and  then  runs  downwards  and  forwards  in  front  of 
the  internal  iliac  and  its  anterior  divisions.  Where  this  division 
of  the  internal  iliac  splits  into  its  branches,  the  ureter  bends 
backwards  and  is  crossed  to  the  inside  by  the  uterine  artery. 
(Fig.  32.)  The  ureter  then  turns  forwards  at  the  level  of  the 
internal  os,  and  at  a  distance  of  about  half  an  inch  from  it  runs 
along  the  side  of  the  vagina  for  a  little  way,  finally  bending 
over  it  so  as  to  enter  the  junction  between  the  vagina  and 
bladder.  It  perforates  the  latter  organ  just  above  the  middle 
of  the  anterior  vaginal  wall,  and  obliquely  enters  the  viscus 
a  little  lower  down. 

*   Weiner  med.  IVoch.,  Nos.  45  and  46,  1882. 

t  New  York  Med.  Joimi.,  May  3rd,  1884. 

\  Dis.  of  Women,  1885,  p.  534. 


15 


Hysterectomy  for  Malignant  Disease. 

History. — It  is  probable  that  excision  of  the  uterus  was 
practised  by  the  ancient  Greeks,  but  it  is  certain  that  the 
operation  was  subsequently  forgotten.  Soranos  of  Ephesus,  in 
his  book  on  Diseases  of  Women,  published  a  century  before  Christ, 
speaks  of  the  operation.  It  is  probable,  however,  that  it  was 
performed  for  prolapse  only.  We  hear  nothing  of  hysterectomy 
till  1560,  when  Andreas  a  Cruce  is  said  to  have  performed  it. 
In  1 81 3  Langenbeck  successfully  removed  the  whole  uterus,  for 
what  was  supposed  to  be  cancer.  The  reality  of  his  operation 
was  questioned ;  but,  when  the  patient  died  nearly  thirty  years 
later,  it  was  proved  at  the  post-mortem  examination  that  he  had 
removed  the  whole  organ.  Mikulicz'''  tells  us  that  one  Gutberlet 
received  a  prize  in  Vienna,  in  1814,  for  proposing  a  mode  of 
removing  the  uterus  not  unlike  that  of  Freund.  In  1822  Sauter  of 
Constance  had  the  first  successful  vaginal  extirpation  for  cancer; 
but  a  urinary  fistula  remained.  In  1828  Blundell  recorded  four 
cases  of  removal  of  the  uterus  for  cancer,  only  one  being 
successful.  In  1829  Recamier  registered  one  success;  but  this 
was  followed  by  failures  in  the  hands  of  Siebold  in  1831,  of 
Delbech  in  1839,  and  others  ;  so  that  the  operation  fell  into 
disuse  till  1879,  when  Czerny,f  struck  with  the  report  of  Lan- 
genbeck's  case,  re-introduced  the  operation  with  a  success. 
Billroth,  Mikulicz,  Schroeder,  Condereau,  Hennig,  Freund, 
and  others,  soon  followed  ;  and  the  operation  now  took  its  place 
among  established  proceedings  in  surgery. 

Freund  struck  out  a  new  path  for  himself  by  using  abdominal 
section.  Crede  modified  Freund's  operation  by  making  a 
resection  of  the  pubes.  Massari,  Spiegelberg,  Baum,  and  others, 
proposed  modifications  more  or  less  ingenious.  But  Freund's 
operation  has  died  out.  It  has  had  a  mortality  of  nearly  seventy 
per  cent,  in  106  published  cases,  and  it  has  been  almost  univer- 

*  Wiener  Med.  Wocli.,  1880,  No.  47,  et  seq. 
t  Zeitschrift  fi'ir  Gebuiishulfe  mid  Dyndkologie,  Bd,  vi,,  Heft,  i.,  1881. 


MORTALITY.  211 

sally  discarded  for  the  vaginal  operation — Kolpo-hysterectomy 
(*:o\7ros=vagina).  To  the  latter  operation  we  shall  therefore 
confine  our  attention. 

Mortality  and  Appreciation. — By  some  authorities  the  operation 
of  removal  of  a  cancerous  uterus  is  absolutely  condemned  as 
unjustifiable.  The  objections  offered  are  mainly  on  three 
grounds — the  high  death-rate,  the  liability  to  recurrence,  and 
the  favourable  results  got  from  partial  removal. 

Kolpo-hysterectomy  has  been  performed  more  than  380  times, 
with  a  general  mortality  of  about  20  per  cent.*  This  death- 
rate  is  spread  over  nearly  50  operators.  Martinf  collected  311 
cases  reported  up  to  the  end  of  1886,  with  a  general  mortality 
of  15. 1  :  this,  I  think,  must  be  a  little  too  favourable.  The 
papers  of  Post  and  Dudley:]:  gave  a  total  of  381  operations,  with 
a  per-centage  mortality  of  20.  Since  then  about  80  operations 
have  been  performed  by  25  surgeons,  or  more,  with  a  mortality 
of  10  per  cent.  Now,  it  may  be  pointed  out  that  ovariotomy 
itself,  in  the  first  300  operations  performed  by  a  few  selected 
surgeons,  had  a  mortality  greater  than  kolpo-hysterectomy  has 
had.  And  it  is  certain  that  if  the  combined  results  of  all  opera- 
tors at  the  present  day  were  tabulated,  the  death-rate  would  be 
nearly  as  large  for  ovariotomy  as  for  kolpo-hysterectomy.  The 
statistics  of  individual  skilled  operators  in  excision  of  the  uterus 
are  nearly  as  favourable  as  the  average  statistics  of  ovariotomy. 
Thus,  Brennecke  has  had  21  cases,  and  Staude  16  cases,  all  suc- 
cessful ;  Fritsch  lost  7  out  of  60  operations  ;  Martin  lost  1 1  out 
of  66  operations ;  and  Sanger,  Olshausen,  Leopold,  and  a  few 
others  have  had  results  nearly  as  brilliant.  Dudley§  has  col- 
lected 38  cases  of  operation  done  in  America  by  22  surgeons, 
with  13  deaths.  It  should  be  noted  that  Bernays  of  St.  Louis 
had  6  cases,  all  recovering ;  and  Bull  of  New  York,  5  cases, 
with  one  death.  It  will  therefore  be  seen  that,  in  skilled  hands, 
the  operation  is  far  from  being  unjustifiable  on  account  of  its 

*  See  Post's  elaborate  paper,  Intern.  Journ.  Med.  Sc,  Jan.,  1886. 

t  Internat.  Med.  Congress,  1887. 

I  Internat.  Journ.  Med.  Sc,  Jan.,  1886. 

§  N.Y.  Med.  Journ.,  July  gth  and  i6th,  1887. 

15  * 


212  KOLPO -HYSTERECTOMY. 

mortality.  The  operation  has  suffered  at  the  hands  of  untrained 
operators ;  but  the  operation  itself  must  not  therefore  be 
condemned. 

With  regard  to  the  objection  urged  against  hysterectomy, 
that  the  disease  is  extremely  liable  to  recur,  we  have  no  trust- 
worthy data  to  argue  from.  This  objection  holds  good  against 
all  operations  for  malignant  disease ;  and  there  is  no  evidence  to 
show  that  this  recurrence  is  more  likely  to  take  place  after  exci- 
sion of  the  uterus  than  after  other  excisions  for  cancer — of  the 
tongue,  for  instance.  Reasoning  on  theoretical  grounds,  we 
might  infer  that  an  organ,  so  much  differentiated  as  the  uterus, 
would  be  as  likely  as  any  to  have  the  disease  limited  for  a 
definite  period.  As  a  matter  of  fact,  in  those  cases  where  the 
after-results  have  been  carefully  noted,  as  in  Fritsch's,  Leopold's, 
Schroeder's,  and  Martin's,  the  per-centage  of  permanent  cures 
is  fully  equal  to  that  got  after  extirpation  of  cancer  in  other 
regions.  No  doubt  recurrence  has  taken  place  more  frequently 
and  more  rapidly  than  it  ought  to  have  done,  because  unsuitable 
cases  have  been  submitted  to  operation. 

Partial  or  cervical  amputation  is  sometimes  compared  with 
total  amputation,  to  the  disadvantage  of  the  latter.  No  fair 
comparison  is  possible.  As  well  might  we  compare  excision  of 
a  small  epitheliomatous  ulcer  of  the  tongue  with  removal  of  the 
whole  organ.  The  operations  are  quite  distinct.  Where  the 
one  is  proper,  the  other  is  improper:  where  the  minor  operation 
is  likely  to  succeed,  it  would  be  wrong  to  perform  the  major. 
And  in  the  case  of  cancer  of  the  uterus,  the  minor  operation  is, 
in  the  large  majority  of  cases,  the  proper  one :  my  own  experi- 
ence is,  that  for  ten  cases  in  which  partial  excision  is  the  proper 
operation,  total  excision  is  called  for  only  once. 

It  should  be  noted  that  certain  authorities  maintain  that 
total  removal  should  be  adopted  for  all  cases  of  cancer  of  the 
uterus,  even  in  those  cases  where  the  disease  is  confined  to  the 
cervix.  Fritsch,  in  particular,  has  identified  himself  with  this 
view ;  and  gives  as  reasons,  besides  the  admitted  ones  of  sub- 
sequent painful  menstruation  and  hability  to  recurrence  after 
the  partial  operation,  the  somewhat  remarkable  one  that  total 


r 

INDICATIONS  AND   CONTRA-INDICATIONS.  213 

extirpation  is  less  difficult  and  less  bloody  than  cervical  ampu- 
tation. He  would  operate,  however,  only  when  operation  is 
easy;  that  is  to  say,  when  the  uterus  can  be  easily  drawn  down. 
Fritsch's  experience  and  his  extraordinary  success  in  the  oper- 
ation give  his  opinion  great  weight.  Additional  strength  has 
been  given  to  Fritsch's  position  by  Schuta  of  Prague,*  who 
states  that  70  per  cent,  of  the  patients  submitted  to  total  extir- 
pation remained  free  of  the  disease  one  year  after  operation; 
while  only  50  per  cent,  remained  free  after  the  partial  operation. 
After  two  years  100  per  cent,  of  the  survivors  were  free  after  the 
radical  operation,  while  only  40  per  cent,  were  free  after  the 
partial  one.     These  statistics,  however,  require  corroboration. 

I  have  no  hesitation  in  expressing  my  belief  that,  in  care- 
fully selected  cases,  the  operation  is  both  justifiable  and  proper. 
The  immediate  mortalitj^  does  not  forbid  it.  Recurrence  is 
almost  certainly  not  more  rapid  than  in  other  operations  for 
cancer,  and  permanent  recovery  is  just  as  likely  to  be  secured. 
And,  finally,  there  seems  to  be  an  almost  unanimous  opinion 
that  death  after  recurrence  is  not  attended  with  so  much  suffer- 
ing ;  that  perforations  of  bladder  and  rectum  are  not  so  liable 
to  take  place  after  the  uterus  is  removed  ;  and  that  existence  is 
prolonged. 

CONDITIONS    FOR   WHICH    OPERATION    MAY    BE    PERFORMED. 
INDICATIONS    AND    CONTRA-INDICATIONS. 

The  varieties  of  malignant  disease  for  which  excision  of  the 
uterus  may  be  performed  are :  epithelioma,  scirrhus,  encepha- 
loid,  and  sarcoma. 

Epithelioma  may  be  found  attacking  the  vaginal  portion  of 
the  cervix,  the  cavity  of  the  cervix,  or  the  interior  of  the  body 
of  the  uterus.  The  varieties  may  be  clinically  spoken  of  as 
epithelioma  of  the  os,  the  cervix,  and  the  body.  On  the  os  the 
diagnosis  is  easy.  The  characteristic  hard,  nodular,  friable 
and  vascular  granulations,  and  the  proneness  to  haemorrhage  on 
being  touched,  are,  with  the  peculiar  acrid  watery  discharges 
*   Wien.  Med.  Presse,  July  3rd,  1887. 


214  KOLPO-HYSTERECTOMY. 

and  certain  other  well-known  symptoms,  sufficiently  diagnostic. 
In  epithelioma  of  the  cervix,  the  development  of  the  cauliflower 
excrescences  is  hindered  by  the  encircling  tissues.  The  new 
growth  infiltrates  the  parenchyma  as  hard  nodular  masses, 
leaving  softened  intervals  of  uninvaded  tissue.  Granulations 
may  protrude  at  the  os,  or  they  may  grow  inwards  towards  the 
uterine  cavity.  The  epitheliomatous  granulations  soon  break 
down,  and  the  cervical  cavity  becomes  a  large,  open,  rounded 
channel,  with  irregular  nodulated  masses  bulging  into  it.  Can- 
cerous discharges  are  said  to  come  on  earlier,  and  to  be  more 
abundant,  in  this  than  in  the  previous  form. 

Epithelioma  of  the  body,  as  a  primary  disease,  is  not  so  rare 
as  it  is  frequently  supposed  to  be.  Its  behaviour  is  very  similar 
to  what  is  found  when  the  disease  attacks  the  cervical  mucous 
membrane.  There  is  greater  enlargement  of  the  fundus,  less 
marked  hardening  of  the  cervix,  and  it  is  frequently  associated 
with  symptoms  of  uterine  contraction  or  spasm.  The  diagnosis 
is  made  certain  by  dilatation  of  the  cervix  and  introduction  of 
the  finger. 

In  every  case  of  doubtful  diagnosis,  a  piece  of  the  granu- 
lations should  be  removed  and  examined  under  the  microscope. 

As  to  operative  treatment.  In  every  case  of  epithelioma 
confined  to  the  vaginal  portion  of  the  cervix,  amputation  of  the 
cervix  alone  is,  in  my  opinion,  called  for.  And  as  the  majority 
of  examples  of  epithelioma  of  the  uterus  are  of  this  limited 
nature,  the  greater  number  of  amputations  will  be  partial. 

Cancer  of  the  cervix  may  occupy  the  lower  portion  of  the 
canal,  or  extend  upwards  through  its  whole  length.  The  selec- 
tion of  partial  or  total  hysterectomy  must  depend  on  the  extent 
of  the  disease.  It  is  possible  to  remove  the  whole  cervix  and 
some  part  of  the  uterine  body  without  entering  the  peritoneum, 
and  in  many  cases  it  may  be  ascertained  with  a  considerable 
degree  of  probability  that  such  operation  is  well  clear  of  the 
disease.  But  epithelioma  in  the  cavity  of  the  uterus  burrows  more 
extensively  than  on  the  os,  and  infiltration  may  have  extended 
some  distance  beyond  the  limits  of  the  superficial  and  palpable 
growth     Such  cases  can  be  cured  only  by  total  hysterectomy. 


SARCOMA   OF  THE   UTERUS.  215 

For  epithelioma  of  the  fundus  and  body  of  the  uterus,  total 
hysterectomy  alone  is  permissible. 

Parenchymatous  cancer  of  the  cervix  may  be  either  scirrhus 
or  encephaloid :  diagnosis  between  the  two  is  rarely  possible 
till  the  disease  is  too  advanced  for  operation.  It  is  known  by 
the  increased  tumefaction  of  the  cervical  tissue  ;  by  its  general 
density,  marked  at  several  points  by  masses  of  specially  hard 
consistence  ;  by  the  dark-red,  angry  colour  of  the  visible  parts  ; 
and  by  the  tenderness  on  pressure.  Scirrhus  is  harder  than 
encephaloid,  and  is  more  liable  to  form  multiple  masses  of 
induration.     The  progress  in  both  is  very  rapid. 

Scirrhus  or  encephaloid  may  attack  the  fundus,  and  may 
develop  towards  the  uterine  cavity  or  towards  the  peritoneum. 
In  the  early  stages  it  is  exceedingly  difficult  to  diagnose  paren- 
chymatous disease  of  the  body  of  the  uterus  from  simple 
myoma.  Undeniable  evidence  is  afforded  only  when  ulceration 
takes  place.  But  much  may  be  inferred  from  the  urgency  of 
the  symptoms  as  to  bleeding,  pain,  the  rapidity  of  progress  with 
attendant  cachexia,  and  the  nature  of  the  discharges. 

Sarcoma  of  the  uterus  is  a  rare  disease,  and  is  not  easily 
diagnosed.  Haemorrhages,  a  watery  discharge  "  like  the  wash- 
ings of  meat  "  (Schroeder),  moderate  enlargement  of  the  uterus, 
often  markedly  in  one  direction,  and  rapid  increase  of  the 
growth,  suggest  the  disease.  There  may  not  be  much  pain, 
and  such  pain  as  is  found  is  usually  intermittent  and  of  the 
nature  of  uterine  colic.  The  growth  is  soft,  often  semi-fluc- 
tuating, and  it  grows  irregularly,  while  still  continuing  as  one 
mass.  In  1888  I  removed,  in  the  Bristol  Royal  Infirmary, 
a  sarcoma  of  the  uterus  containing  great  quantities  of  blood- 
clot.  The  patient  died  within  three  weeks  with  secondary 
deposits  in  the  lungs,  and  suppurative  peritonitis.  In  the 
beginning  of  this  year  I  performed  a  similar  operation,  removing 
a  mass  of  sarcoma  as  large  as  the  fist.  The  patient  made  an 
excellent  recovery,  and  the  uterus  was  reduced  to  its  normal 
bulk.     This  was  intended  as  a  preliminary  to  total  removal ; 


216  KOLPO-HYSTERECTOMY. 

but  the  patient,  with  the  chances  of  recurrence  fairly  put  before 
her,  decided  against  the  operation. 

In  malignant  disease  of  the  uterus,  where  removal  of  the 
whole  organ  is  contemplated,  the  grave  nature  of  the  operation 
demands  that  the  indications  and  contra-indications  should  be 
peculiarly  definite  and  unmistakable.  They  are  in  no  way 
different  from  those  in  force  with  reference  to  malignant  disease 
elsewhere ;  but  the  risk  to  life  from  the  primary  operation 
is  so  great,  that  special  weight  must  be  given  to  any  element 
which  is  likely  to  interfere  with  success.  The  liability  to  recur- 
rence in  a  given  case  of  epithelioma  of  the  lip  may  appear  to  be 
greater  than  in  one  of  epithelioma  of  the  cervix  uteri  after 
removal ;  but  the  immediate  danger  after  operation  from  the 
one  is  so  much  less  than  after  the  other,  that  the  one  operation 
might  be  surgically  permissible  when  the  other  would  not. 

Before  proceeding  to  operation  in  any  given  case  of  malig- 
nant disease,  the  most  careful  and  rigid  scrutiny  must  be 
instituted,  not  only  into  the  amount  of  local  disease  and  its 
limits,  but  into  the  general  condition  of  the  patient.  Marked 
anaemia,  evident  cachexia,  or  a  faulty  condition  of  any  of  the 
vital  organs  or  viscera,  at  once  forbids  operation.  The  patient 
must  be  in  fair  health,  with  a  prospect  of  average  longevity 
from  general  soundness  of  organs  apart  from  the  malignant 
disease. 

Locally,  a  precise  examination  by  vagina  and  rectum  must 
reveal  complete  absence  of  extension  of  disease  to  any  sur- 
rounding organ  or  gland,  to  peritoneum,  broad  ligament,  bladder, 
or  rectum.  One  finger  in  the  rectum  and  another  in  the  vagina 
may  cause  the  cervix  and  the  wall  of  the  bowel  to  glide  over 
each  other ;  and  a  sound  in  the  empty  bladder  may,  to  a  less 
extent,  elicit  the  same  symptom  for  that  organ.  Bimanual 
examination  will  detect  thickening  of  the  broad  ligaments  and 
enlargement  of  glands.  The  uterus  must  be  freely  movable  in 
all  directions,  and  the  movements  ought  not  to  be  associated 
with  severe  deep  pelvic  pains.  Local  extension  of  the  growth 
to  the  vagina,  of  course,  contra-indicates  operation. 


CERVICAL   AMPUTATION. 


217 


CERVICAL    AMPUTATION. 

Although  this  operation  for  cervical  cancer  is  not  strictly 
within  the  limits  of  this  work,  and  was  omitted  in  the  first 
edition,  I  now  include  it,  because  it  is  germane  to  what  follows, 
and  because  it  makes  complete  the  account  of  the  operative 
treatment  of  uterine  cancer.  I  confine  my  description  to  a  short 
account  of  the  operation  which  I  have  performed  for  the  past 
five  years  with  uniform  success.  The  cases  are  too  few  to 
draw  conclusions  from ;  but,  judging  from  the  behaviour  of 
patients  submitted  to  the  operation,  I  believe  that  one  may  go 

on  operat- 
ing with  a 
mortality 
under  2  per 
cent. 

The  va- 
gina is  dis- 
inf ec t  ed 
thoroughly 
by  irriga- 
tion before 
operation, 
and  by 
swabbing 
at  the  time 
of  opera- 
tion. The 
patient  is 
placed  in 
the  litho- 
tomy posi- 
tion and 
kept  there 
by   means 

of  Clover's  crutch.  (Fig.  33.)  The  cervix  is  caught  in  power- 
ful locking  volsella,  by  means  of  which  the  uterus  is  forcibl}' 
dragged   down :    these    are  handed  over  to  an  assistant,  who 


Fig.  33. 

Clover's  Cni'.ch.        One-eighth  size. 


218  KOLPO-HYSTERECTOMY. 

directs  the  movements  of  the  uterus  according  to  the  instruc- 
tion of  the  surgeon.  The  only  instruments  necessary  are,  two 
Spencer  Wells's  large  compression  forceps,  a  scissors  curved 
on  the  flat,  and  a  straight  uterine  probe. 

The  mucous  membrane  surrounding  the  cervix,  well  clear  of 
the  disease,  is  divided  circularly  with  the  scissors.  With  the 
forefinger  of  the  left  hand,  and  the  scissors  in  the  right,  the 
cervical  mucous  membrane  is  dissected  or  peeled  off  in  an 
upward  direction,  in  front  and  behind,  but  not  at  the  sides,  as 
high  as  possible.  The  dissection  is  made  close  to  the  uterus  in 
front  to  avoid  the  bladder  and  ureters,  and  behind  to  avoid 
perforation  of  the  peritoneum ;  the  dissection  may  be  carried 
higher  in  front  than  behind.  Practice  on  the  cadaver  will  soon 
enable  one  to  judge  by  touch  when  the  upward  limits  of  safety 
have  been  reached  ;  these  are  known  by  the  increased  resistance 
met  with.  At  the  sides,  where  the  broad  ligaments  are  inserted 
and  the  uterine  arteries  are  met  with,  no  dissection  is  made,  but 
cellular  tissue  is  stretched  and  peritoneum  is  pushed  aside.  The 
cervix  is  now  cleared  of  mucous  membrane  up  to  the  limits  of 
undetachable  peritoneum  :  it  must  be  noted,  however,  that  the 
peritoneum  at  the  sides  is  less  closely  adherent  than  in  front 
and  behind  ;  and  two  pouches  can  be  formed  between  the  layers 
of  the  broad  ligaments,  higher  up  than  the  highest  limits  of  the 
peritoneal  reflexions  from  the  uterus.  The  peritoneum  is,  in 
fact,  stripped  from  the  broad  ligaments  for  some  distance  along 
the  sides  of  the  uterus ;  and  between  the  two  layers  of  peri- 
toneum lies  a  stratum  of  cellular  tissue  containing  the  uterine 
vessels.  This  layer  of  undetached  cellular  tissue  is  caught 
between  the  fore  and  middle  fingers  of  the  left  hand,  and 
stretched  laterally  while  the  assistant  drags  the  uterus  in  an 
opposite  direction,  thus  clearing  the  lower  sub -peritoneal 
portions  of  the  broad  ligament,  which  contain  important 
vessels,  for  the  application  of  the  large  compression  forceps. 
The  blades  of  the  forceps  are  pushed  as  high  up  as  possible  in 
the  tracks  of  the  fingers  and  firmly  locked,  first  on  one  side  and 
then  on  the  other.  If  there  has  been  bleeding  from  the  epithe- 
liomatous  tissue,  from  compression  or  tearing  by  the  volsella, 


KOLPO-HYSTERECTOMY.  219 

this  bleeding  at  once  stops  when  the  forceps  are  appUed. 
Indeed,  the  continuation  of  the  haemorrhage  after  the  application 
of  both  pairs  of  forceps  I  should  regard  as  indicating  that  they 
were  not  properly  applied. 

The  cellular  tissue  between  the  forceps  and  the  side  of  the 
uterus  is  now  divided  by  scissors.  Such  division  nearly  always 
permits  the  uterus  to  be  dragged  down  lower.  The  uterine 
probe  is  now  placed  inside  the  cavity  as  a  guide  to  the  lines  of 
division.  The  uterine  tissue  is  divided  obliquely  upwards  by 
the  scissors,  the  division  all  round  converging  to  the  probe  as  a 
centre.  The  fingers  of  the  left  hand  push  the  loose  tissues  out 
of  the  way  of  the  scissors,  while  the  assistant  manipulates  the 
uterus  by  volsella  and  probe,  so  as  to  assist  the  division.  The 
cervix  and  a  considerable  portion  of  the  body  of  the  uterus  may 
be  removed  in  this  way  without  any  trouble  from  haemorrhage. 
The  uterine  mucous  membrane  may  be  removed  in  its  whole 
length  without  much  difficulty,  if  it  is  divided  while  it  is  gradually 
pulled  down  after  the  muscular  tissue  has  been  cut  through. 

The  gap  in  the  uterus  is  swabbed  out  with  an  antiseptic 
lotion ;  a  pad  of  antiseptic  wool  closes  the  vagina  and  surrounds 
the  handles  of  the  forceps,  which  are  left  in  situ.  In  twenty- 
four  or  thirty-six  hours  the  forceps  are  removed.  Daily  irriga- 
tion of  the  vagina  may  be  continued  for  a  week  or  longer,  and 
in  a  fortnight  the  patient  may  be  permitted  to  get  up. 

KOLPO-HYSTERECTOMY. 

An  extraordinary  amount  of  literature  has  accumulated 
around  the  description  of  Kolpo-hysterectomy.  Much  of  it 
represents  early  crude  and  tentative  proceedings  which  have 
been  generally  ignored  or  abandoned;  but  some  of  the  described 
methods  have  survived  the  natural  processes  of  selection  and 
evolution,  and  have  now  crystallised  into  generally  accepted 
plans  of  operation.  Finality  has  not  yet  by  any  means  been 
obtained,  and  permissible  variations  in  each  step  of  the  opera- 
tion may  be  properly  referred  to. 

The  operation  may  be  conveniently  described  in  successive 
stages. 


220  KOLPO-HYSTERECTOMY. 

Preparatory.  —  Two  or  three  days  must  be  devoted  to 
thoroughly  cleansing  the  whole  of  the  parts  concerned  in, 
and  contiguous  to,  the  seat  of  operation.  The  external  parts, 
the  folds  between  the  labia  at  the  top  of  the  thighs  and  around 
the  clitoris  and  pubes,  are  washed  at  least  once  a  day  with  soap 
(preferably  with  pure  potash  soap)  and  hot  water.  The  vagina 
is  irrigated  twice  daily  with  some  trustworthy  antiseptic,  such 
as  1-30  carbolic  acid  or  1-1500  perchloride  solution.  After 
irrigation,  iodoform  powder  is  to  be  insufflated,  and  a  plug  of 
cotton  wool,  impregnated  with  antiseptic  material  (iodoform  is 
suitable),  is  to  be  inserted,  and  removed  for  the  next  irrigation. 
Some  writers  recommend  that  the  cavity  of  the  uterus  should 
be  purified ;  but,  if  the  uterus  has  to  be  turned  over,  risk  of 
infection  may  be  avoided  by  placing  a  sponge  between  the 
cervix  and  the  peritoneum ;  while  if  it  is  not  turned  over,  the 
proceeding  is  unnecessary.  A  few  surgeons  go  so  far  as  to 
recommend  that  the  protruding  and  foul  granulations  should 
be  removed  some  days  before  removing  the  whole  organ.  The 
objections  to  this  plan  are  probably  less  strong  than  to  the  use 
of  the  curette  at  the  time  of  operation,  which  prolongs  the 
operation,  and  obscures  the  field  by  extravasation  of  blood, 
while  the  loss  of  blood  may  weaken  the  patient.  When  the 
patient  is  placed  ready  for  operation,  a  final  and  thorough 
douching  with  a  strong  antiseptic  lotion  will  be  instituted. 
The  bladder  and  the  rectum  are,  of  course,  thoroughly 
emptied. 

The  best  position  of  the  patient  is  that  of  perineal  lithotomy  ; 
and  the  posture  is  best  maintained  by  Clover's  crutch  (Fig.  33), 
which  keeps  the  knees  apart,  and  maintains  flexure  of  the  thighs 
on  the  pelvis  by  means  of  a  strap  carried  round  the  neck. 
Ordinary  lithotomy  straps,  joining  wrist  and  ankle,  permit 
movements  of  the  limbs,  and  require  an  assistant  to  keep  them 
still.  The  table  must  be  of  convenient  height,  so  as  to  bring 
the  parts  easily  within  the  reach  of  manipulation  and  sight. 
A  few  surgeons  prefer  Sims's  position. 

Fixation  and  Manipulation  of  the  uterus;is  managed  by  means 
of  a  powerful  volsella,  with  three  or  four  broad  interlocking 


CLEARING   THE  CERVIX.  221 

teeth.  Many  surgeons  recommend  the  use  of  a  thick  Hgature, 
carried  through  the  cervical  tissue.  But  a  hgature,  however 
thick,  is  more  hable  to  tear  the  tissue  than  volsella  of  proper 
shape  and  dimensions  ;  and  an  assistant  cannot  move  the  uterus 
about  in  the  vagina,  as  the  operator  directs  him,  with  so  much 
rapidity  and  precision  by  a  thread  as  by  a  strong  stiff  instru- 
ment. Volsella  need  be  in  the  way  of  the  operator  no  more 
than  a  string. 

The  surgeon  pulls  down  the  uterus  as  far  as  possible  by 
means  of  the  volsella,  and  then  hands  it  over  to  an  assistant. 
The  next  step  is  : 

Dissection  of  the  vaginal  nmcoiis  membrane  off  the  cervix.  If  the 
patient  is  stout,  lateral  retractors  may  be  of  advantage  in  giving 
more  room  and  more  light.  In  most  cases  the  fingers  of  the  left 
hand  will  be  quite  sufficient  to  expose  the  parts.  In  those  cases 
where  the  cervix  can  be  brought  outside  the  vulva,  retractors 
will  not  be  necessary. 

A  scissors,  carved  on  the  flat,  is  made  to  cut  through  the 
mucous  membrane  around  the  cervix,  at  a  distance  well  clear  of 
the  disease.  As  a  general  rule,  it  will  be  wise  to  carry  this  line 
as  high  up  as  possible,  short  of  the  limits  of  danger  to  bladder 
or  ureters  in  front,  or  rectum  behind.  When  the  uterus  has 
been  much  dragged  down,  the  normal  relations  to  bladder  and 
rectum  are  disturbed ;  and  if  deep  cuts  are  rashly  made,  these 
viscera  may  be  wounded.  (Fig.  34.)  The  finger  moved  over 
the  cervix,  and  judging  of  the  mobility  of  the  mucous  membrane 
covering  it,  will  always  be  a  reliable  guide. 

The  mucous  membrane  is  now  elevated  from  the  cervix, 
connecting  cellular  tissue  being  divided  by  forefinger  and 
scissors.  A  catch  forceps  placed  on  the  anterior  flap  and 
handed  to  the  assistant,  who  pulls  it  forward  while  he  depresses 
the  cervix  with  the  volsella,  will  facilitate  the  dissection  in 
front ;  while  a  reversed  manipulation  will  be  of  equal  advantage 
behind.  Laterally,  no  cutting  must  be  made  after  the  mucous 
membrane  is  divided.  The  cellular  tissue  must  be  pushed  up 
as  high  as  possible  by  the  finger  without  tearing  it ;  frequently 
the  upward  limit  wiU  be  defined  by  a  feeling  of  pulsation  in  the 


222 


KOLPO-HYSTERECTOMY. 


uterine  arteries.     Under  all  circumstances,  in  the  dissection,  it 
is  a  wise  plan  to  keep  close  to  the  uterus. 

A  sound  in  the  bladder  is  by  many  operators  considered  an 
assistance.     If  there  is  any  doubt  as  to  the]  position  of  that 


Fig.   34.       {After  Savage.) 

To  show  Disturbed  Relations  of  Parts  when  Uterus  is  forcibly 
pulled  doivnwards  by  Volsella. 

B,  Bladder  ;  U,  Uterus ;  R,  Rectum ;  P,  Pubic  Symphysis  ;  O,  Ovary  ; 

T,  Fallopian  Tube ;  L,  Round  Ligament ;  g,  Overlying  Ureter ; 

e,  Volsella  grasping  Cervix. 

viscus,  and  any  apprehension  of  its  being  injured,  then  the 
sound  ought  to  be  inserted.  But  if  the  rule  to  keep  close 
to  the  uterus  is  followed,  and  if  the  finger  has  been  made 
familiar  with  the  feel  of  the  parts  by  practice  on  the  cadaver, 
the  sound  will  rarely  be  wanted.  A  wound  accidentally  made 
in  the  bladder  must  be  at  once  sutured.  Schmidt,  in  one  opera- 
tion, had  the  misfortune  to  cut  away  an  inch  of  the  ureter  along 
with  the  uterus ;  he  at  once  performed  nephrectomy,  and  the 
patient  recovered. 

Opening  the  Peritoneum. — When  the  mucous  membrane   has 
been  cleared  from  the  cervix  as  high  up  as  the  peritoneum, 


DIVIDING   THE  BROAD  LIGAMENTS.  223 

that  membrane  is  perforated  in  front  and  behind,  and  the 
abdominal  cavity  is  entered.  The  forefinger  is  the  best 
perforator.  Above  the  internal  os,  the  peritoneum  is  closely 
adherent  to  the  uterus  anteriorly  and  posteriorly,  and  here  the 
finger  may  be  pushed  through  it  by  a  little  judicious  manipu- 
lation. If  it  is  more  than  ordinarily  tough,  and  it  seems  to  be 
yielding  and  stretching  in  front  of  the  finger,  a  Lister's  sinus 
forceps  sharply  pushed  through  it  will,  after  separation  of  the 
blades,  make  an  opening  large  enough  to  admit  the  finger.  The 
opening  is  enlarged  in  front  and  behind  by  tearing  with  the 
finger  on  both  sides  as  far  as  the  broad  ligament.  Braithwaite 
makes  a  great  point  of  leaving  the  peritoneum  behind  intact  till 
that  membrane  in  front  has  been  fully  opened,  hoping  in  this 
way  to  prevent  access  of  blood,  cancerous  or  septic  matters. 
Before  making  the  posterior  opening  the  parts  are  thoroughly 
cleansed. 

A  soft  sponge  is  now  pushed  through  the  opening  into  the 
posterior  cul-de-sac,  and  left  there.  It  serves  to  protect  the 
bowels  and  keep  them  out  of  the  way,  while  it  absorbs  any 
effused  fluids  and  lies  between  the  general  cavity  and  any  pos- 
sible infection  from  the  cancerous  uterus. 

Division  of  the  Broad  Ligaments. — The  most  difficult  and  deli- 
cate step  in  the  whole  proceeding  is  the  separation  of  the  uterus 
from  the  broad  ligaments,  and  the  securing  of  the  vessels  lying 
in  them  against  bleeding.  For  this  purpose  an  almost  endless 
variety  of  plans  has  been  devised.  The  ligaments  have  been 
secured  in  mass  by  ecraseur,  wire,  silk,  and  elastic  ;  they  have 
been  divided  and  seared  by  cautery ;  and  they  have  been  secured 
in  separate  divisions  by  loops,  chain  ligatures,  and  continuous 
sutures.  To  facilitate  manipulation,  the  uterus  has  been  turned 
upside  down  in  backward  and  in  forward  direction,  and  it  has 
been  completely  bisected  from  fundus  to  os.  Minor  varieties  of 
these  varieties  have  been  recommended  and  carried  out ;  as,  for 
instance,  the  division  after  ligation  of  the  lower  portion  of  the 
broad  ligaments;  then  turning  the  uterus  upside  down,  and 
ligating   and   dividing  the   upper   portions.     One  writer  is  of 


224 


KOLPO.HYSTERECTOMY . 


opinion  that  the  Fallopian  tube  ought  to  have  a  catgut  ligature 
of  its  own ;  and  special  needles  are  accredited  with  special 
virtues  for  the  placing  of  ligatures. 

The  best  results  will  be  got  from  the  selection  of  an  efficient 
plan  which  is  at  the  same  time  simple,  and  endeavouring  to 
perfect  it.  The  application  of  ligatures  is  alwaj's  difficult ;  in 
the  most  skilled  hands  it  has  sometimes  failed  to  check 
bleeding.  The  simplest  plan  is  undoubtedly  that  of  temporary 
pressure  by  forceps  or  clamp,  and  it  can 
undoubtedly  be  made  efficient.  Quite  recently 
a  good  deal  of  evidence  in  favour  of  this  plan 
has  appeared  in  the  journals.  Richelot  of 
Paris,  in  particular,  has  devoted  attention  to 
the  method  with  conspicuous  success. 
Miiiler  and  Landau  strongly  recommend 
the  method,  and  many  other  operators 
speak  favourably  of  it.  I  have  for 
some  time  advocated  this  principle, 
and  had  devised  a  special  clamp  for 
the  practical  carrying  of  it  out,  some 
time  before  it  was  mentioned  in  the 
journals. 

The  instrument  (Fig.  35)  is  simply  a 
straight  clamp  with  long  and  powerful 
handles,  and  grooves  on  its  lateral  as- 
pect to  guide  a  small  knife  which  is 
intended  to  cut  through  the  clamped 
ligaments.  It  is  deeply  slotted  on  its 
compressing  aspect,  to  prevent  slipping ; 
elsewhere  it  is  smooth  and  rounded. 
Through  the  posterior  opening  the  fore- 
finger is  carried  over  the  top  of  one 
broad  ligament,  hooking  it  down  as 
far  as  possible.     This  manoeuvre  may 

be  facilitated  by  a  blunt  hook,  handed  over  to  an  assistant. 
The  posterior  blade  is  now  carried  upwards  along  the  finger, 
at  a  distance  of  about  half  an  inch  from  the  uterus,  and  the 


Fig.  35. 

The  Authov's  Clamp  for 

Ko  Ipo-Hysterectomy . 

One-third  size. 


FORCI-PRESSURE   TO   BROAD   LIGAMENTS.  225 

end  hooked  over  the  top  of  the  ligament.  Its  handle  is  pressed 
backwards  on  the  perineum.  The  anterior  blade  is  intro- 
duced in  front  of  the  ligament,  parallel  to  the  posterior  blade, 
and  its  end  is  locked  by  a  simple  mechanism  into  the  end 
of  the  posterior  blade.  The  clamp  is  then  closed,  and  the 
handles  screwed  up  tightly  outside  the  vulva.  A  second  clamp 
is  similarly  applied  on  the  opposite  ligament.  When  both 
clamps  are  applied,  the  knife  is  run  up  the  grooves  and  the 
ligaments  divided  on  the  uterine  side  of  the  clamps,  when  the 
uterus  is  freed.  Or  scissors  may  be  used  for  this  division.  The 
instruments  may  be  easily  removed  at  the  end  of  one  or  two 
days,  when  the  natural  process  of  vascular  closure  will  provide 
against  the  occurrence  of  haemorrhage. 

Mr.  Knowsley  Thornton  has  devised  a  modification  of  this 
clamp,  in  which  the  handles,  attached  by  a  bayonet  joint,  may 
be  removed,  and  in  which  the  grooves  for  the  knife  are  done 
away  with.  The  use  of  these  instruments  renders  the  operation 
a  very  simple  one.  It  is  possible,  in  the  deadhouse,  to  remove 
the  uterus  by  means  of  them  in  five  minutes,  and  leave  the  parts 
in  a  condition  anatomically  and  surgically  satisfactory  ;  and  on 
the  operating  table,  the  proceeding  ought  not  to  occupy  more 
than  half  an  hour. 

The  use  of  strong  compression  forceps,  to  be  removed  after 
one,  two,  or  three  days,  would  secure  the  same  result  with 
somewhat  less  facility  and  greater  cumbersomeness.  Miiller  * 
has  advocated  the  use  of  two  pairs  of  forceps,  one  pair  to  each 
broad  ligament,  and  supports  his  recommendation  by  records  of 
five  cases,  with  one  death.  The  disadvantages  of  the  use  of 
forceps  are,  that  several  pairs  would  have  to  be  applied,  and 
left  in  the  vagina ;  while  both  sides  of  the  uterus  could  scarcely 
be  secured  against  bleeding  before  the  uterine  connections  were 
severed. 

A  word  of  warning  must  be  given  as  to  the  danger  of  leaving 

on  pressure  forceps  or  clamps  too  long.     I  lost  a  patient,  from 

whom  I  had  removed  a  sarcomatous  uterus,  through  sloughing 

of    the    broad    ligaments    where    they    were    compressed    by 

*  Ccntralbl.f.  Gynak.,  1887,  No.  12. 

16 


226  KOLPO-HYSTERECTOMY. 

forceps.  The  operation  was  not  a  difficult  or  prolonged  one — 
it  occupied  about  half  an  hour, — but  the  patient  was  very 
much  reduced.  The  power  of  forceps  or  clamp  is  enormous, 
and  pressure  exerted  by  them  for  a  very  short  time  may 
cause  necrosis.  If  they  might  be  safely  removed  at  the  end  of 
ten  or  fifteen  hours,  as  I  believe  they  might,  this  risk  would  be 
minimised.  As  one  gets  more  experience  and  skill  in  the  opera- 
tion, one  is  inclined  to  trust  solely  to  ligatures.  For  one  who  is 
not  accustomed  to  perform  operations  of  this  sort,  the  use  of 
clamp  or  pressure  forceps  is  no  doubt  advisable. 

In  some  cases  where  the  uterus  is  considerably  enlarged, 
as  in  mahgnant  disease  of  the  fundus,  or  as  in  a  case  on  which 
I  operated  where  pregnancy  co-existed,  the  tops  of  the  broad 
ligament  lie  beyond  the  reach  of  the  finger,  and  the  whole 
structures  are  voluminous,  the  clamps  are  unsuitable,  and 
either  forci-pressure  or  deligation  must  be  instituted.  In  the 
apphcation  of  either  method,  I  believe  that  turning  the  uterus 
upside  down  will  be  found  an  advantage  :  and  this  I  should 
select  in  preference  to  all  other  methods  which  have  been 
recommended.  Complete  rotation  of  the  uterus  on  its  long 
axis  materially  shortens  the  depth  of  the  broad  ligaments, 
brings  them  more  fully  within  the  field  of  operation,  and  leaves 
the  most  important  stage  of  the  proceeding — division  of  the 
uterine  arteries — to  the  last,  when  it  is  also  rendered  most  easy. 
Against  the  plan  of  turning  the  uterus  upside  down  it  is 
urged  that  thereby  a  cancerous  and  perhaps  foul  mass  is  brought 
into  contact  with  the  peritoneum.  To  avoid  this  risk  the  super- 
added operation  of  excising  the  cervix  has  been  recommended 
and  performed.  Now  it  is  easy  enough,  by  the  use  of  germicides, 
to  render  the  cervix  not  only  aseptic  but,  if  the  fluid  is  strong 
enough,  actively  antiseptic.  But  all  such  risks  may  easily  be 
avoided  by  the  expedient,  ordinary  enough  in  abdominal  surgery, 
•of  placing  a  sponge  between  the  possibly  noxious  substance  and 
the  peritoneum. 

It  matters  little  whether  the  uterus  is  turned  backwards  or 
forwards.  If  rotation  can  be  performed  by  the  finger  alone,  it 
is  most  easily  carried  out  in  the  backward  direction,  with  the 


LIGATION  OF  BROAD  LIGAMENTS.  227 

finger  in  the  posterior  opening  and  hooked  over  the  fundus 
uteri.  If  the  finger  does  not  suffice,  anterior  rotation  by  means 
of  forceps  ma}^  be  carried  out.  A  firm  hold  of  the  anterior 
surface  is  taken  with  catch-forceps,  and  the  uterus  is  pulled 
down  as  much  as  possible  ;  a  second  hold  is  secured  higher  up, 
and  so  on,  one  above  the  other,  till  the  fundus  is  grasped,  and 
the  uterus  pulled  down  and  completely  inverted.  The  fundus 
now  lies  in  the  vagina,  and  perhaps  presents  at  the  vulva,  and 
the  upper  insertions  of  the  broad  ligaments  are  within  sight 
and  reach. 

Where  it  is  possible  to  apply  it  properly,  a  satisfactory 
ligature  is  probably  better  than  the  best  forci-pressure.  With 
an  inverted  uterus,  deligation  of  the  broad  ligaments  presents 
no  special  difficulties.  Firstly,  a  powerful  Wells'  forceps  grasps 
as  much  as  possible  of  one  broad  ligament,  close  to  the  uterus, 
and  a  strong  silk  ligature  is  carried  round  a  corresponding  depth 
of  the  ligament  at  a  proper  distance  beyond.  Braithwaite 
found  that  it  was  not  necessary,  in  two  successful  cases,  to  place 
forceps  on  the  uterine  side  of  the  divided  tissues ;  bleeding  was 
checked  by  the  forcible  traction  on  the  uterus.  The  intervening 
tissue  is  divided  with  scissors.  Two  or  three  successive  pieces 
of  ligament  are  so  treated,  and  one  side  of  the  uterus  is  set  free. 
The  other  side  is  similarly  treated,  and  the  whole  uterus  is  then 
removed.  The  broad  ligaments  are  thus  secured  by  three  or 
four  ligatures  on  each  side,  which  are  cut  off  short.  If  there 
is  any  doubt  as  to  the  security  of  the  deligation  at  any  points, 
catch-forceps  are  placed  on  the  visible  vessels,  and  these  are 
either  ligatured  subsequently,  or  the  forceps  are  left  hanging 
and  removed  next  day  or  the  day  after. 

Ovaries  and  Fallopian  tubes,  if  they  are  healthy,  need  not 
be  removed.  The  only  reason  for  removing  the  appendages 
would  be  the  prevention  of  moliminal  pains.  In  one  patient  on 
whom  I  operated,  leaving  ovaries  and  tubes,  two  years  ago, 
backache  at  the  menstrual  period  was  very  severe  for  some 
months.     In  another  patient  there  was  little  or  no  trouble. 

When  the  uterus  is  pulled  down,  and  particularly  if  it  is 
inverted,  the  broad  ligaments  are  stretched  and  tense.     As  soon 

16  * 


228  KOLPO-HYSTERECTOMY. 

as  the  uterus  is  cut  off,  the  hgaments  recoil,  become  flaccid,  and 
retract,  tending  to  cast  hgatures  loose.  Therefore  the  ligatures 
should  be  tightly  drawn,  and  they  should  have  a  considerable 
hold  upon  the  tissues.  These  precautions  ought  to  be  specially 
observed  in  the  lower  portions  of  the  ligaments,  where  the 
uterine  arteries  lie.  And  it  must  be  remembered  that  it  is  here 
where  the  risk  of  wounding  the  ureters,  or  of  including  them  in 
the  ligatures,  is  greatest.  These  dangers  are  enhanced  by 
inversion  of  the  uterus.  They  are  minimised  by  a  thorough 
separation  of  surrounding  cellular  tissue  in  the  early  stages, 
and  by  keeping  always  as  close  to  the  uterus  as  possible. 

The  Peritoneal  and  Vaginal  Wounds  do  not  require  suture.  No 
better  results  are  got  from,  suture  than  from  leaving  them  to  fall 
into  apposition,  and  unite  as  best  they  can.  Some  surgeons 
recommend  that  the  peritoneum  should  be  sutured  to  the 
vagina  ;  others,  that  the  vagina  alone  should  be  sutured ;  and 
others  say  that  if  the  peritoneum  is  sutured,  the  vagina  may  be 
left  to  look  after  itself.  But  suturing  of  any  sort  has  been 
proved  to  be  unnecessary.  A  positive  objection  to  the  employ- 
ment of  sutures,  whereby  flaps  are  kept  in  close  apposition,  is 
that  the  discharges  which  ooze  from  their  surfaces  are  locked  up 
and  may  become  sources  of  septic  infection.  The  parts  fall 
naturally  into  apposition,  and  remain  apposed.  It  is  true  that 
the  best  and  quickest  healing  will  be  got  if  like  tissue  is 
apposed  to  like ;  and  advantage  ought  to  be  taken  of  the 
remarkable  rapidity  with  which  inflamed  serous  surfaces  co- 
here. Further,  it  is  advisable  that  all  oozing  from  rawed 
surfaces  should  find  its  way  into  the  vagina,  rather  than  into 
the  peritoneum. 

This  end  may  be  simply  effected  in  the  withdrawing  of  the 
sponge  placed  inside  the  abdomen  through  the  opening.  It  pulls 
down  the  flap  with  it,  and  in  so  doing  leaves  serous  surfaces  in 
contact  and  rawed  surfaces  closed  in,  while  it  leaves  the  flaps  so 
that  discharges  from  them  run  into  the  vagina.  The  serous 
membranes  first  unite,  and,  as  soon  as  they  close,  the  peritoneal 
cavity  is  shut  off". 


DRAINAGE.  229 

Drainage  of  some  sort  is  advisable  for  the  first  day  or  two. 
If  the  clamps  are  used,  they  will  act  as  drains.  If  not,  a  glass 
drainage-tube  of  ordinary  size  and  shape  is  as  good  as  any.  It 
should  be  placed  very  carefully,  without  disturbing  the  relations 
of  the  serous  and  mucous  flaps.  A  T-shaped  tube  has  the 
advantage  that  it  will  not  slip  out  of  the  abdomen ;  but  it  has 
the  disadvantage  that  it  cannot  be  removed  without  breaking 
down  recent  adhesions. 

For  the  first  twenty-four  hours  sero-sanguinolent  fluid  will  be 
discharged  through  the  tube ;  thereafter  for  a  day  or  two,  serous 
or  sero-purulent  fluids,  in  diminishing  amount.  At  the  end  of 
three  or  four  days,  if  all  goes  well,  the  tube  may  be  removed. 

In  view  of  the  fact  that  ail  fluids  lying  in  Douglas's  pouch 
have  a  tendency  to  undergo  decomposition,  and  that  in  hys- 
terectomy there  may  be  actual  entrance  of  air  or  vaginal 
secretions  into  the  abdominal  cavity,  it  will  be  a  wise  plan  at 
stated  intervals  to  irrigate  through  the  drainage-tube.  This 
may  be  easily  done  by  passing  a  catheter  attached  to  an 
irrigator  along  the  drainage-tube  to  the  abdominal  cavity,  and 
sending  a  stream  of  warm  lotion  through  it.  When  the  fluid 
returns  clear,  irrigation  may  be  stopped. 

A  roll  of  antiseptic  gauze  or  cotton  passed  up  the  drainage- 
tube  will  act  as  an  antiseptic  plug,  and  as  a  capillary  extractor 
of  fluids.  Pluggmg  of  the  vagina  is  troublesome  and  un- 
necessary. If  the  tube  is  surrounded  wuth  antiseptic  wool 
where  it  lies  between  the  labia,  and  if  the  external  parts  are 
kept  thoroughly  clean  and  sweet,  there  is  little  danger  of  septic 
infection.  Indeed,  it  is  notorious  that  tampons  m  the  genital 
passages  have  of  themselves  a  strong  tendency  to  become 
putrid. 

A  good  working  method  is  to  draw  the  urine  through  the 
catheter  every  five  or  six  hours.  When  the  bladder  is  emptied 
the  wool  surrounding  the  end  of  the  drainage  tube  is  with- 
drawn, and  the  cavity  is  irrigated.  Then  the  external  parts  are 
thoroughly  cleansed ;  boro-glyceride  is  smeared  all  over  them, 
and  a  new  dressing  is  applied. 

It  has  been  recommended  that  the  patient's  shoulders  should 


230  KOLPO-HYSTERECTOMY. 

be  raised,  so  as  to  permit  of  downward  drainage.  This  is  quite 
unnecessary  ;  and  it  may  be  harmful  by  encouraging  the  access 
of  air.  The  extensive  experience  of  drainage  through  the 
anterior  parietes  has  proved  that  intra-abdominal  pressure  is 
quite  sufficient  to  force  free  fluids  upwards  through  a  patent 
opening ;  and  to  prevent  the  admission  of  air,  it  would  be  wiser 
to  have  the  external  end  of  the  tube  in  the  vagina  on  a  higher 
level  than  the  end  in  the  abdominal  cavity.  But  a  plug  of 
cotton  wool,  while  encouraging  the  escape  of  fluid,  will  prevent 
the  insufflation  of  air. 

The  general  treatment  requires  no  special  description.  The 
histories  of  recorded  cases  seem  to  show  that  there  is  more 
than  the  ordinary  tendency  to  tympanites.  The  use  of  the 
rectum  tube,  the  exhibition  of  turpentine  enemas,  and  the 
administration  of  saline  purges,  will  most  efficiently  remove 
this  condition.  In  all  respects  the  general  management  is 
similar  to  that  after  other  abdominal  operations. 

Complications  and  Accidents. — Wounds  of  the  bladder  or  ureter 
are  much  less  frequent  than  might  be  expected.  The  bladder 
is  most  likely  to  be  wounded  during  the  early  stages  before  the 
peritoneum  is  opened,  and  while  the  relations  are  disturbed  by 
the  uterus  being  dragged  down.  The  best  way  to  avoid  the 
accident  is  to  keep  close  to  the  uterus  and  push  the  bladder 
forwards  out  of  the  way.  If  the  bladder  is  wounded,  it  ought 
to  be  at  once  sutured. 

Wound  of  the  ureter  is  a  more  serious  aff'air,  and  may 
demand  extirpation  of  the  kidney.  It  is  most  likely  to  suff"er 
injury  at  the  end  of  the  operation ;  and  more  particularly  is  it 
liable  to  be  included  in  the  lower  ligatures  applied  to  the 
broad  ligament.  Keeping  close  to  the  uterus  is  here  also 
the  best  mode  of  avoiding  the  risk.  But  the  accident  very 
rarely  happens. 

Cases  are  recorded  where  intestinal  fistula  has  been  caused 
by  pressure  from  the  drainage-tube. 

Haemorrhage,   either  during  or   following  the  operation,  is 


COMPLICATIONS.  231 

the  chief  risk.  If  the  bleeding  points  cannot  be  included  in 
ligatures,  pressure-forceps  are  left  attached.  After  the  oper- 
ation, if  haemorrhage  takes  place,  a  Ferguson's  speculum  must 
be  passed  and  the  source  of  the  bleeding  sought  for.  When 
discovered,  the  simplest  method  of  checking  it  is  to  apply  and 
leave  on  a  powerful  compression  forceps.  For  general  oozing, 
a  stream  of  water  heated  to  iio°  Fah.  may  be  safely  and 
advantageously  passed  over  the  bleeding  surface. 

The  ordinary  complications  of  operations  in  the  pelvis  may 
occur:  such  are — pelvi-peritonitis,  phlebitis,  lymphadenitis. 
They  are  to  be  treated  on  ordinary  principles. 


Hysterectomy  for  Intractable  Inversion. 

With  the  help  of  the  admirable  repositors  of  Aveling  and 
others,  it  now  rarely  happens  that  an  inverted  uterus  cannot  be 
replaced.  But  it  does  sometimes  happen  that,  in  spite  of  the 
most  skilled  and  patient  trials,  an  inversion  cannot  be  cured, 
while  the  resulting  condition  to  the  patient  is  so  grave  that 
a  means  of  cure  is  urgently  demanded.  Under  such  circum- 
stances hysterectomy  may  be  called  for. 

History. — Paulus  ^gineta  speaks  of  the  removal  of  a  pro- 
lapsed uterus  which  had  mortified  as  having  been  carried  out 
with  success.  But  this  probably  was  merely  the  removal  of  a 
sloughing  polypus.  In  1678  Arnould  excised  an  inverted  uterus, 
with  fatal  result.  Deleurye,  Assilini,  de  Bardol,  Beaufils,  Faivre, 
Hunter,  and  others,  have  operated  by  ligature,  mostly  without 
success.  At  the  end  of  the  eighteenth  century  Baudelocque  made 
an  elaborate  study  of  the  treatment  of  uterine  inversions,  and 
formulated  some  very  sensible  conclusions.  He  clearly  differen- 
tiated between  an  extruded  polypus  and  an  inverted  uterus,  and 
laid  down  definite  rules  for  diagnosis  and  treatment.  In  recent 
times,  Denuce*  has  been  conspicuous  in  advancing  our  know- 
ledge of  the  subject. 

The  diagnosis  of  complete  uterine  inversion  is  sufficiently 
easy.  It  can  be  mistaken  only  for  a  polypus.  Conjoined 
manipulation,  under  anaesthesia  if  necessary,  will  show  the 
presence  of  the  uterus  in  its  normal  position  in  polypus,  and 
its  absence  in  inversion.  The  finger  in  the  rectum  may  further 
detect  the  funnel-shaped  depression  into  which  the  round  liga- 
ments and  Fallopian  tubes  pass,  and  in  which  occasionally  the 
uterine  appendages  may  be  detected.  Pulling  down  the  uterus 
aids  the  diagnosis  in  those  points.  The  absence  of  os  uteri, 
the  continuity  of  the  tumour  with  the  uterine  cervix  at  every 
point,  and  occasionally  the  presence  of  the  two  small  openings 
*  Traite  de  VInversion  Uterine. 


MODES  OF  OPERATING.  233 

at  the  cornua  leading  into  the  Fallopian  tubes,  will  be  deter- 
mined. Polypus  may  be  associated  with  inversion :  here  extra 
care  must  be  observed. 

THE    OPERATION. 

A  good   many  methods   of    removing   the   inverted   uterus 

have   been   employed.      They   may  be    classified    under   three 

heads : 

(i)  Immediate  removal,  at  one  sitting. 

(2)  Gradual  removal,  by  compression  or  cautery. 

(3)  Excision  and  compression  combined. 

Immediate  removal  has  been  performed  by  a  simple  cutting 
operation,  by  crushing  with  ecraseur,  and  by  the  actual 
cautery.  Velpeau  is  credited  with  a  success  after  excision. 
McClintock,  Sims,  Denuce,  and  others,  have  had  successes 
with  the  ecraseur.  Ligature,  immediately  followed  by  excision, 
and  searing  of  the  raw  surface  after  excision,  has  also  been 
employed  more  than  once  with  success. 

But  no  method  of  immediate  removal  has  had  favourable 
results :  according  to  Schroeder,  a  57  per  cent,  mortality  may 
be  expected.  The  objection  to  this  method  is  the  very  serious 
one,  that  it  leaves  the  peritoneum  exposed  to  infection  from  the 
traumatic  and  suppurative  processes  induced  in  the  stump. 
Even  if  adhesions  form  after  deligation  or  charring,  they  are 
too  flimsy  to  act  as  an  efficient  barrier  to  the  entrance  of 
septic  products. 

Gradual  removal  by  sloughing,  induced  by  compression  or 
cautery,  has  had  better  results.  Of  all  methods  of  gradual 
compression,  the  elastic  ligature  has  been  found  most  successful. 
Courty  has  had  a  few  successes  by  the  use  of  the  galvano- 
cautery,  applied  slowly  and  at  several  sittings.  The  ecraseur 
and  the  wire  serre-nceud  have  been  used  in  this  way  also. 

But  here  also  the  mortahty  has  been  high — 27  per  cent. 
And  gradual  strangulation  causes  severe  pain,  and  frequently 
begets  serious  nervous  disturbance — sometimes  even  alarming 
collapse.  The  presence  of  a  large  sloughing  mass  in  the  vagina 
is  neither  agreeable  nor  free  from  danger. 


234  HYSTERECTOMY  FOR   INVERSION. 

Compression  and  excision  combined  have  given  the  best  results — 
17  per  cent,  mortahty.  The  principle  of  the  proceeding  is,  to 
keep  up  compression  for  a  few  days,  till  strong  adhesions  have 
formed  on  and  around  the  inner  serous  surfaces,  and  then  to 
amputate  the  uterus  below  the  site  of  constriction.  This  is  the 
plan  recommended  by  Schroeder,  and  successfully  modified  by 
Pouissot,  Despres,  and  more  recently  by  Schiilein. 

The  constricting  agent  may  be  a  simple  ligature  of  silk  or 
catgut ;  or  an  elastic  ligature,  prevented  from  slipping  by 
previously  charring  a  circle  of  tissue  with  the  galvanic  cautery ; 
or  an  ecraseur,  such  as  that  of  Cintrat  or  Koeberle.  As 
simple  and  efficient  as  any  is  the  application  of  a  strong 
ligature  of  silk,  and  the  superimposition  of  an  elastic  ligature  in 
the  groove  so  caused.  The  silk  ligature,  pulled  verj^  tightly, 
fixes  and  steadies  the  underlying  tissues  ;  the  elastic  keeps  up  a 
continuous  pressure  on  the  receding  tissues  after  the  silk  liga- 
ture gets  loose  ;  and,  at  the  end  of  three  or  four  days,  closure  of 
vessels  and  adhesion  of  peritoneal  surfaces  may  be  confidently 
expected. 

The  uterus  will  have  been  well  soaked  in  glycerine  of  carbolic 
acid,  or  some  similar  antiseptic  that  will  penetrate  its  tissue.  In 
spite  of  this,  a  gangrenous  odour  will  usually  appear  in  a  few 
days.  On  the  third  day,  or  later  according  to  the  behaviour  of 
the  strangulated  uterus,  amputation  may  be  performed.  This 
operation  must  be  carried  out  with  as  little  disturbance  of  parts 
as  possible.  A  series  of  cuts  with  scissors  whose  blades  are  at 
right  angles  to  the  handles,  and  whose  movements  are  guided  by 
a  finger  in  the  vagina,  would  fulfil  this  requisite.  The  section  is 
to  be  made  close  to  the  ligature,  so  as  to  completely  remove  all 
tissue  which  is,  or  is  likely  to  become,  necrosed.  A  cylindrical 
speculum  cautiously  introduced  into  the  vagina  will  afford  a 
good  view  of  the  stump  left.  If  it  seems  healthy  and  compact, 
the  ligatures  may  be  removed  and  the  raw  surface  smeared  with 
an  antiseptic.  The  vagina  is  then  thoroughly  cleansed  and  kept 
clean,  and  the  stump  is  left  to  its  fate. 


Hysterectomy  for  Myoma. 

Perhaps  "  Removal  of  Uterine  Myoma  by  Abdominal  Sec- 
tion "  would  be  a  better  name  than  the  above  for  the  operation 
to  be  described.  In  some  cases,  it  is  possible  to  remove  the 
growth  without  removing  any  part  of  the  uterus ;  in  others, 
a  part  of  the  uterus  may  be  removed,  while  the  uterine  cavity  is 
not  entered  ;  while,  in  a  third  class,  the  uterine  cavity  is  entered, 
and  varying  amounts  of  its  structure  removed,  up  to  complete 
hysterectomy.  But,  as  the  operation  is  very  generally  known 
by  the  name  given,  it  is  here  adopted. 

History. — Lizars  in  1825,  and  Dieffenbach  in  1826,  encoun- 
tered uterine  myoma  on  opening  the  abdomen ;  but  neither 
endeavoured  to  remove  the  growth. 

In  1837  Granville  is  said  to  have  unsuccessfully  removed  a 
pedunculated  uterine  fibroid.  In  1843  Heath  operated  unsuccess- 
fully, and  in  1844  Clay  of  Manchester  operated  with  like  result. 
Burnham,  an  American,  is  credited  with  the  first  success,  in  1853 ; 
and  in  1855  Kimball,  another  American,  had  a  success.  Pean, 
Hegar,  Billroth,  Kaltenbach,  and  Schroeder,  on  the  Continent, 
did  much  to  advance  the  position  of  the  operation  ;  in  our  own 
country,  Keith,  Bantock,  Tait,  Thornton,  and  others,  have  been 
conspicuous  among  operators  and  teachers.  For  magnitude  of 
operations,  perfection  of  methods,  and  brillianc}'  of  results, 
Keith  holds  a  commanding  position  among  all  operators. 

Mortality  and  Appreciation.  Indications  to  Operate. — It  is  im- 
possible so  to  present  the  statistics  of  hysterectomy  for 
fibroids  as  to  give  a  fair  idea  of  the  results  which  may 
be  fairly  expected  to-day.  Thus,  Bigelow,*  in  a  total  of  573 
cases,  gives  311  recoveries  and  241  deaths — the  results  in 
some   not    being   recorded.     Vautrin,|   in   his   valuable   mono- 

*  Amer.  Joiirn.  Obstet.,  Nov.,  1883,  et  seq. 
\  Du  Traitement  Chirurgical  des  Myomes  Utirines,  Paris,  1886. 


236  HYSTERECTOMY  FOR  MYOMA. 

graph,  classifies  operations  for  myoma  as — myomectomies,  or 
simple  removal  of  a  subserous  myoma ;  enucleations ;  partial 
amputations  of  the  uterus  ;  and  complete  supra-vaginal  hyster- 
ectomies. He  gives  tabular  descriptions  of  operations  under 
each  head.  In  32  myomectomies  there  were  24  recoveries ;  in 
23  enucleations  there  were  only  9  recoveries ;  in  36  partial 
amputations  there  were  26  recoveries ;  and  in  82  supra-vaginal 
amputations  there  were  44  recoveries. 

Gusserow's  statistics,  comprising  359  cases  operated  upon 
between  the  years  1878  and  1885,  give  237  recoveries  and  122 
deaths — a  mortality  of  33.9  per  cent.  If  to  these  are  added  180 
cases  operated  upon  by  Schroeder,  Olshausen,  Braun,  and 
TaufFer,  we  got  a  total  of  539  cases,  with  a  30  per  cent, 
mortality. 

The  general  mortality  in  the  last  few  years  is  nothing  like  so 
great  as  this ;  and  in  the  hands  of  a  few  operators  it  does  not 
exceed  15  per  cent.  Keith's  mortality,  in  most  unpromising 
cases,  is  only  8  per  cent. ;  Tait's  mortality,  in  his  latest  cases,  is 
very  low;  and  Bantock  and  Thornton  are  getting  results  equally 
good.  On  the  Continent,  half-a-dozen  operators  could  be  named 
whose  mortality  is  under  15  per  cent.  Into  the  further  details  of 
the  abundant  statistics  it  is  not  necessary  to  go.  It  is  clear  that, 
in  the  hands  of  properly  qualified  operators,  the  proceeding, 
from  the  point  of  view  of  immediate  mortality,  is  as  justifiable  as 
any  other  major  operation. 

A  further  and  more  important  consideration  is  whether,  with 
a  death-rate  even  of  one  in  ten,  the  operation  is  ever  justifiable. 
It  is  urged  by  several  writers  that  uterine  myoma  is  not  a  fatal 
disease ;  that  palliative  treatment  will  always  tide  the  patient 
over  periods  of  danger,  and  often  effect  a  cure ;  that  the  life- 
history  of  the  disease  is  limited  ;  and  that  a  death-rate  of  even 
five  per  cent,  absolutely  forbids  surgical  operation.  On  the 
other  hand,  it  is  argued  that  myoma  is  often  fatal ;  that,  in 
many  cases,  medicinal  treatment  is  utterly  futile ;  that  a  con- 
siderable number  of  cases  go  on  causing  danger  or  serious 
trouble  long  after  the  usual  period  for  menopause ;  and  that,  in 
a  selected  series  of  cases,  the  operation  is  not  only  justifiable 


INDICATIONS  FOR   OPERATION.  237 

but  necessary.  It  would  be  tedious  and  useless  here  to  go  over 
the  often-repeated  arguments  for  and  against  the  operation.  As 
usual,  the  safe  course  is  the  middle  one. 

Of  all  operators,  want  of  caution  can  with  least  justice  be 
urged  against  Keith.  The  indications  which  he  gives  for 
operation  are  as  follows : 

"I.  In  very  large  rapidly  growing  tumours  of  all  kinds  in 
young  women.  By  a  large  tumour,  I  mean  a  tumour  upwards 
of  20  lb. 

'*  2.  In  all  cases  of  real  fibrous  cystic  tumours,  if  they  can 
be  removed.     Also  in  all  cases  of  suppurating  tumours. 

"3.  In  most  of  the  cases  of  the  soft  oedematous  tumours. 
These  often  grow  to  an  enormous  size — far  larger,  often,  than 
any  ovarian  tumour.  I  have  seen  one  that  would  not  be  less 
than  200  lb.  in  weight.  Sometimes  large  quantities  of  red 
serum  can  be  removed  with  much  relief,  and  I  have  several 
times  been  able  by  this  means  to  carry  patients  over  the  meno- 
pause, when  the  necessity  for  further  puncturing  ceases.  These 
tumours  seem  to  open  up  the  broad  ligaments  more  than  the 
ordinary  hard  tumour,  and  some  that  I  have  removed  have  had 
very  extensive  pelvic  attachments.  These  tumours  are  much 
reduced  by  free  purgation. 

"4.  In  cases  of  large  bleeding  fibroids  of  any  age,  provided 
that  the  patients  are  not  approaching  fifty  years  of  age,  and 
provided  that  the  lives  are  practically  useless,  and  that  further 
experience  in  the  operation  shall  show  that  the  mortaily  of 
hysterectomy  is  likely  to  diminish. 

"  5.  In  certain  cases  of  tumours  surrounded  by  free  fluid,  the 
result  of  peritonitis,  provided  that  the  fluid  shows  a  tendency 
to  re-accumulate  after  two  or  three  punctures.   .   .  ." 

These  are  clear  and  distinct  indications  for  the  performance 
of  hysterectomy,  the  operation  being  begun  with  the  view  of 
finishing  it  as  such.  Another  indication  may  be  given  as  fol- 
lows :  An  operation  is  begun  with  the  view  of  removing  the 
uterine  appendages ;  this  is  found  impracticable,  and  an  exami- 
nation reveals  that  myomectomy  or  hysterectomy  may  be  per- 
formed without  undue  risk  :  in  such  a  case  the  major  operation 


238  HYSTERECTOMY  FOR   MYOMA. 

may  be  proceeded  with.  Since  Keith  wrote  the  above,  Apostoli's 
method  of  treating  myoma  has  been  introduced,  and  from  the 
trial  he  has  given  it  he  beheves  that  it  will  be  of  value  as  rescuing 
many  cases  from  operation.  It  is  as  yet  too  early  to  speak 
definitely  and  conclusively  on  the  subject. 

Symptoms  and  Diagnosis  of  Uterine  Myoma. — The  well-known 
classification  of  uterine  fibroids  into  interstitial,  sub-mucous, 
and  sub-peritoneal,  sufficiently  indicates  the  position  which  such 
growths  may  occupy  with  regard  to  the  uterine  walls.  With 
regard  to  the  region  in  which  they  lie,  they  are  spoken  of  as 
fibroids  of  the  fundus,  the  body,  or  the  cervix.  They  are  most 
frequently  globular  in  shape,  especially  when  they  are  not  of 
large  size  ;  but  they  may  assume  most  irregular,  even  grotesque, 
forms.  In  size,  they  vary  from  that  of  a  pea  to  dimensions  as 
great  as  the  capacity  of  the  abdomen.  They  are  of  hard  dense 
texture,  cutting  with  a  peculiar  gritty  sensation,  and  exhibit 
a  dull  white  or  glistening  surface  on  section,  which  has  been 
likened  to  mother-of-pearl.  Frequently  they  contain  cysts  in 
their  substance,  and  occasionally  they  are  soft,  oedematous, 
almost  fluctuating.  Often  they  are  traversed  by  enormous 
vascular  channels. 

A  developed  fibroma  may  be  said  to  live  outside  the  uterine 
fibre,  even  when  it  is  encapsuled  in  its  substance.  Courty  well 
describes  it  as  parasitic  ;  sometimes  its  nutrition  may  be 
said  to  be  carried  on  by  imbibition.  In  such  cases  the  fibroid  is 
completely  encapsuled,  lying  in  a  bed  of  loose  cellular  tissue, 
and  may  be  enucleated  like  a  foreign  body.  These  tumours  are 
liable  to  undergo  changes  in  structure.  After  inflammation  they 
may  become  very  dense,  being  little  else  than  a  mass  of  fibrous 
tissue  with  scanty  muscular  elements  ;  and  this  fibrous  tissue 
may  undergo  general  or  peripheric  calcification.  They  may 
become  fatty,  and  undergo  liquefaction  with  the  formation  of 
cystic  cavities.  Occasionally  they  suppurate,  or  even  become 
gangrenous.  Finally  they  may  undergo  regressive  involution, 
and  completely  disappear.  It  is  generally  observed  that  uterine 
fibroids  increase  in  size  during  pregnancy. 


SIGNS  OF  MYOMA.  239 

The  first  sign  is  usually  metrorrhagia.  At  first  the  excess  of 
bleeding  occurs  only  during  the  normal  period ;  then  it  comes 
on  in  the  intervals  as  well ;  and  in  the  worst  cases  there  is  a 
continuous  discharge  of  blood,  in  varying  quantities,  at  all 
times.  The  blood  is  frequently  discharged  in  clots  of  consider- 
ablejnagnitude.  Pains  of  a  down-bearing  expulsive  character, 
and  shooting  across  the  hips  and  down  the  thighs,  with  feelings 
of  weight  or  pressure  inside  the  pelvis,  and  dragging  sensations 
in  the  loins,  are  frequently  complained  of.  In  the  intervals  of 
bleeding,  a  glairy  semi-purulent  fluid  is  discharged.  Symptoms 
of  mechanical  pressure  on  the  pelvic  organs,  such  as  d3'suria, 
excessive  frequency  of  micturition,  constipation,  or  diarrhoea, 
are  frequently  observed. 

The  physical  signs  vary  according  to  the  size  of  the  tumour, 
snd  its  situation  in  relation  to  the  uterus  and  the  abdominal 
cavity.  Through  the  parietes  a  tumonr  is  felt  arising  out  of 
the  pelvis — hard  and  incompressible,  in  most  instances  ;  occa- 
sionally soft  or  even  fluctuating ;  usually  rounded  and  smooth 
all  over,  but  not  infrequently  covered  with  bosses  ;  movable 
from  side  to  side,  if  it  does  not  fill  the  abdominal  cavity,  and 
moving  in  company  with  the  uterus  as  felt  through  the  vagina. 
Absolute  continuity  of  uterus  and  tumour  may  be  made  out  by 
vaginal  and  rectal  palpation.  The  uterine  sound  will  show 
enlargement  of  the  cavity,  with  some  deviation  in  its  direction. 
From  being  a  simple  canal  some  two  or  three  inches  in  length, 
the  uterine  cavity  may  be  elongated  and  spread  out  into  a  flat 
fan-shaped  space  in  which  the  sound  can  be  freely  moved  from 
side  to  side.  In  some  cases,  where  the  growth  lies  on  one  side 
and  is  mainly  extra-mural,  the  uterus  is  forcibly  pushed  over 
to  the  other  side.  This  lateral  version  of  the  uterus  is  often 
described  as  being  a  valuable  presumptive  sign  of  myoma.  In 
other  cases  the  uterus  is  dragged  upwards  into  the  abdomen,  or 
pushed  downwards  on  the  perineum,  according  to  the  direction 
in  which  the  tumour  grows  from  its  seat  of  attachment. 

Interstitial  fibroids  cause  general  hypertrophy  of  the  uterine 
walls,  with  vascular  engorgement  of  the  mucosa.  Located  in 
the  fundus,  they  may,  when    small,  cause  marked  version  or 


240  HYSTERECTOMY  FOR  MYOMA. 

flexion ;  when  large,  they  produce  displacements — upward, 
downward,  and  lateral — of  the  most  varied  description. 

Sub-mucous  fibroids  may  often  be  felt  through  a  softened 
and  dilated  cervix.  Their  tendency  to  become  polypoid  and  to 
be  extruded  by  uterine  action  is  well  known.  They  set  up  great 
irritation  of  the  uterine  mucous  membrane,  causing  much  muco- 
purulent and  sanguineous  discharge.  The  uterine  cavity  is  at 
the  same  time  dilated  and  encroached  upon  ;  the  uterine  wall 
on  the  side  opposite  the  growth  is  spread  over  it  and  in  close 
contact  with  it.  These  signs  can  be  made  out  only  with  the 
help  of  the  uterine  sound. 

Sub-peritoneal  fibroids  tend,  at  an  early  stage,  to  rise 
upwards  into  the  abdominal  cavity.  There  may  be  little  change 
in  the  uterus  as  regards  either  shape  or  position :  there  is 
usually,  however,  some  uterine  enlargement  as  well  as  displace- 
ment, which  may  be  found  to  vary  at  different  examinations. 
Sub-peritoneal  growths,  if  multiple,  are  usually  small;  if  single, 
they  are  rarely  larger  than  a  child's  head.  They  are  freely 
movable,  and  the  associated  movements  of  the  uterus  may  be 
not  more  marked  than  in  ovarian  tumours.  Sometimes  their 
pedicles  are  as  long  as  two  or  three  inches ;  and  cases  have 
been  recorded  where  their  connection  with  the  uterus  has  been 
completely  severed,  and  they  have  lived  either  through  the 
vessels  in  adventitious  adhesions  or  by  imbibition  from  the 
peritoneum.  Their  symptoms  are  rarely  urgent ;  often,  there 
is  little  beyond  discomfort  and  metrorrhagia  to  complain  of. 
Hardness  is  said  to  be  a  characteristic  of  sub -peritoneal 
fibroids. 

THE    OPERATION. 

The  nature  of  the  operation  for  uterine  myoma  will  vary 
according  to  the  situation  and  attachments  of  the  tumour. 
The  varieties  of  operation  have  been  classified  by  Vautrin*  as 
follows : 

I.  For  the  removal  of  sub-peritoneal,  pedunculated  myomata 
— simple  myomectomy. 

*  Du  TvaiUment  Chirurgical  des  Myomes  Utdrines,  Paris,  1886,  p.  124. 


NATURE  OF  OPERATION.  241 

2.  For  the  removal  of  certain  tumours  encapsuled  in  uterine 
tissue — enucleation. 

3.  For  the  removal  of  tumours  incorporated  in  the  uterine 
tissue,  in  which  it  is  impossible  to  remove  the  growth  without 
opening  the  uterine  cavity — partial  amputation  of  the  uterus. 

4.  For  the  removal  of  tumours  with  extirpation  of  the  uterus 
above  the  insertion  of  the  vagina — supra-vaginal  amputation  of  the 
uterus. 

5.  For  the  removal  of  multiple  myomata  with  enlargement 
of  the  uterus,  in  certain  cases — complete  extirpation  of  the  uterus. 

This  classification — simple,  natural,  and  consistent  with  the 
pathology  as  it  is — does  not  fully  satisfy  practical  requirements. 
Thus,  no  distinct  line  can  be  drawn  between  partial  and  supra- 
vaginal amputation  of  the  uterus.  Complete  extirpation — that 
is,  removal  of  every  particle  of  uterine  tissue,  leaving  the  vagina 
and  the  broad  ligaments  only  as  pedicle — is  very  rarely  called 
for  ;  and  when  it  is,  the  details  of  operation  differ  so  little  from 
partial  amputation,  or  amputation  through  the  cervix,  that  a 
separate  description  is  not  necessary.  Indeed,  from  a  practical 
point  of  view,  a  classification  of  operations  depending  on  whether 
or  not  the  growth  extends  between  and  opens  up  the  layers  of 
the  broad  ligament  would  probably  be  of  more  practical  value 
than  that  of  Vautrin. 

The  operations  for  uterine  myoma  are  here  described  as : 

1.  Simple  myomectomy  or  removal  of  the  tumour  without  any 
of  the  uterine  tissue,  by  excision  or  by  enucleation,  and  without 
entering  the  uterine  cavity.  , 

2.  Hysterectomy,  total  or  partial ;  or  removal  with  the  tumour 
of  more  or  less,  or  all,  of  the  uterine  tissue  proper — usually, 
with  entrance  of  the  cavity. 

This  subdivision  broadly  corresponds  to  the  all-important 
one  of  pedicle  and  no  pedicle,  and,  still  more  broadly,  to  intra- 
peritoneal and  extra-peritoneal  completion  of  the  operation. 

It  may  truly  be  said  of  the  operation  for  myoma,  that  the 
exact  mode  of  operating  can  never  be  decided  upon  till  the 
abdomen  is  opened  and  the  condition  ascertained  by  digital 
examination.     In  cases  of  small  growths  which  are  not  pedun- 

17 


242  ,  HYSTERECTOMY  FOR  MYOMA. 

culated,  removal  of  the  uterine  appendages  may  be  indicated ; 
then  the  major  operation  is  not  called  for.  In  cases  of  simple 
pedunculated  sub-peritoneal  growth,  ligation  of  the  pedicle  and 
removal  of  the  growth  may  be  sufficient.  Again  :  other  growths, 
encapsuled  and  lying  near  to  the  uterine  surface,  may  be  pro- 
perly treated  by  enucleation.  But,  in  the  majority  of  instances 
which  call  for  removal  of  the  tumour,  a  complicated  operation, 
involving  delicate  and  difficult  proceedings  to  separate  the  mass 
from  the  bladder  or  to  enucleate  it  from  the  broad  ligaments, 
will  be  necessary.  The  operative  details  are  schemed  out  after 
inspection ;  they  are  finally  determined  upon  after  the  tumour 
has  been  turned  out,  and  are  frequently  modified  as  the  opera- 
tion goes  on. 


Myomectomy. 


The  incision  is  made  in  the  middle  hne  below  the  umbilicus, 
and  is  long  enough  to  admit  the  whole  hand.  The  lower  end  of 
the  incision  should  not  approach  the  pubes  too  closely,  as  the 
bladder  in  these  cases  is  often  elevated.  It  is  usually  found 
that  the  parietes  are  abnormally  vascular  in  cases  of  uterine 
m5'oma.  A  complete  examination  of  the  mass  is  then  made  by 
the  hand  carried  through  the  opening,  and  the  advisability  of 
removal  is  decided  upon.  The 
incision  is  prolonged  upwards 
with  scissors,  guided  by  the  fore- 
finger, as  far  as  is  necessary  for 
delivering  the  tumour  without 
bruising  the  edges  of  the  wound. 
Tait's  screw  (Fig.  36)  with  broad 
blade  is  placed  in  the  tumour, 
and  used  as  a  handle  by  which 
to  pull  it  out  and  to  manipulate 
it.  In  the  case  of  large  tumours, 
two  such  screws,  placed  at  some 
distance  apart,  may  be  found  of 
great  assistance  in  the  necessary 
manipulations.  When  the  tumour 
is  removed  from  the  abdomen, 
large  sponges  are  packed  inside 
the  cavity  to  keep  the  bowels  in 
place  and  to  absorb  extravasated 
blood. 

Adhesions  to  the  parietes  must 
be  separated  before  the  tumour  can  be  delivered.  Adhesions 
to  bowels  or  omentum  may  be  divided  after  the  tumour 
has  been  delivered,  or  during  its  delivery.  As  the  tumour 
is  being  pulled  out,  great  caution  is  necessary  to  make 
certain    that    adherent    bowel    is    not    torn ;    and    with    this 

17  ^ 


Fig.  36. 

Tait's  Screw  for  Myoma. 
Half  size. 


244  HYSTERECTOMY  FOR  MYOMA. 

object,  the  hand  is  placed  inside  the  abdomen,  under  the 
tumour,  to  ascertain  that  undue  traction  is  not  being  exerted 
on  attached  organs.  Parietal  adhesions  may  usually  be  severed 
by  the  fingers.  Adhesions  to  bowel,  omentum,  or  other  organs, 
are  divided  between  pairs  of  catch  -  forceps  or  double  liga- 
tures. Vessels  in  the  omentum  sometimes  attain  to  enormous 
dimensions,  and  require  great  care  in  their  division  and  ligation. 
If  their  walls  are  very  thin,  seeming  scarcely  strong  enough 
to  carry  a  ligature,  the  vessels  must  be  followed  upwards 
till  a  sufficient  bulk  of  omental  tissue  to  form  soft  packing 
around  the  vessel  is  met  with ;  and  here  the  vessel  is  tied  along 
with  some  of  the  surrounding  tissue.  As  Thornton  points  out, 
much  blood  may  be  lost  by  dividing  vessels  coming  from  solid 
vascular  tumours  ;  such  vessels  do  not  contract  on  division,  as 
they  do  in  adhesions  attached  to  an  empty  and  contracted 
ovarian  cyst-wall. 

Pedunculated  sub-peritoneal  growths  are  removed  after 
securing  the  pedicle.  The  mode  of  treating  the  pedicle  will 
depend  on  its  thickness,  length,  and  vascularity.  In  some  cases 
a  simple  ligature  will  be  sufficient.  Kaltenbach,  Olshausen, 
Billroth,  and  others,  have  related  cases  in  which  simple  ligation 
en  masse  has  proved  efficient.  I  have  successfully  removed  a 
sub-peritoneal  myoma  as  large  as  a  child's  head  in  which  the 
pedicle  was  secured  by  a  simple  silk  ligature,  gradually 
tightened  while  the  tumour  was  being  cut  away.  If  the  pedicle 
is  short,  this  plan  of  coaxing  tissue  off  the  tumour  by  successive 
snips  of  a  scissors  while  the  ligature  is  tightened  on  the  relaxed 
and  isolated  fibres  is  an  excellent  one  ;  certainly  better  than 
simple  deligation,  followed  by  amputation.  The  tissues  may 
always  be  drawn  together  more  closely  after  amputation  than 
before ;  and  by  this  process  of  gradual  constriction,  combined 
with  piecemeal  amputation,  all  the  vessels  are  caught  in  the 
ligature,  and  there  is  no  likelihood  of  their  recoiling  afterwards. 

In  other  cases  the  pedicle  is  too  large  to  be  safely  included  in 
one  ligature,  and  here  it  is  necessary  to  transfix.  A  blunt  needle 
which  will  not  wound  a  vessel  is  used,  and  it  is  inserted  at  a 
convenient  distance  between  uterus  and  tumour,  not  too  close  to 


TREATMENT  OF  THE  PEDICLE.  245 

either.  Thornton  first  ties  in  mass,  and  then  transfixes  and  ties 
doubly  beyond  the  single  ligature.  The  Staffordshire  knot  may 
be  used — supplemented,  if  necessary,  by  a  second  simple  ligature. 
In  fact,  the  mode  of  ligation  must  depend  on  the  nature  of  the 
pedicle ;  and  many  efficient  modes  are  available.  The  use  of 
strong  crushing  or  clamp  forceps  to  diminish  the  bulk  of  the 
pedicle  has  its  disadvantages  as  well  as  its  advantages.  If  the 
pedicle  is  a  broad  one,  the  outlying  vessels  may  be  torn  through 
b}'  the  strong  compressing  blades,  and  escape  from  their  grasp, 
while  only  the  vessels  in  the  centre  are  caught.  Olshausen* 
has  laid  down  directions  as  to  the  mode  of  ligation,  depending 
on  the  thickness  of  the  pedicle.  But  points  of  equal  importance 
are — its  length,  its  density,  and  its  vascularity.  A  thick  pedicle 
which  is  long  and  compressible  may  be  efficiently  secured  in  a 
single  ligature,  when  a  less  thick  one  which  is  short  and  dense 
may  require  multiple  deligation.  No  definite  rules  can  be  laid 
down :  the  surgeon  must  be  guided  by  general  principles. 

Gusserowf  and  others  have  been  able  to  secure  the  vessels 
separately ;  and  where  this  can  be  done,  it  is  undoubtedly  the 
best  plan.  A  separate  ligature  to  each  vessel  produces  a 
haemostasis  which  is  independent  of  retraction  of  vessels  or 
shrinking  of  uterine  fibre.  This  plan  can  be  adopted  only 
where  the  pedicle  is  not  large  and  where  the  vessels  are  not 
numerous. 

The  elastic  ligature  is  favoured  by  some  surgeons,  particularly 
of  the  French  school.  Its  advantages  are  more  conspicuous  in 
cases  where  some  considerable  bulk  of  uterine  fibre  is  included 
in  the  ligature  ;  that  is  to  say,  in  cases  where  atrophy  and 
shrinking  of  the  pedicle  are  likely  to  follow  operation. 

When  the  pedicle  has  been  efficiently  secured,  its  peritoneal 
margins  may  be  drawn  over  the  divided  surface  by  means  of  a 
continuous  suture.  This  diminishes  the  area  of  exposed  raw 
surface,  which  is  liable  to  become  adherent  to  contiguous  intes- 
tine, and  so  lessen  the  risk  of  danger  from  intestinal  obstruction. 
Uterine  stumps  do  not  become  quiescent  so  quickly  as  ovarian 

*  Deutsche  Zeitschr.  f.  Chir.,  Dec.  1881,  p.  171. 
t  Die  Neiibildungen  dcs  Uieyiis,  Stuttg.,  18S6,  p.  103. 


246  HYSTERECTOMY  FOR   MYOMA. 

stumps :    this   is    another   reason    for   taking    every  pecaution 
against  their  begetting  trouble. 

The  pedicle,  in  myomectomy  for  sub-peritoneal  growths,  is 
dropped  inside  the  abdomen,  as  in  ovariotomy.  In  a  few  cases 
the  extra-peritoneal  method  has  been  adopted  j  but  such  a 
course  is  justifiable  only  on  the  proved  impossibility  of  treating 
the  pedicle  otherwise.  Dragging  on,  with  sloughing  in  the  con- 
tiguity of,  a  uterus  which  is  enlarged  and  sensitive  from  the 
presence  of  a  myoma  cannot  be  other  than  dangerous.  The 
clamp  and  extra-peritoneal  treatment  of  the  pedicle  in  myomec- 
tomy for  sub-peritoneal  growths,  is  likely  to  be  more  disastrous 
even  than  in  ovariotomy. 

Enucleation  is  available  in  certain  cases  of  myoma  where  the 
growth  lies  near  to  the  uterine  surface,  and  is  evidently  encap- 
suled.  Spiegelberg*  is  said  to  have  first  practised  enucleation 
with  suture  of  the  uterine  wound.  Martin,  Billroth,  Hegar  and 
Kaltenbach,  and  others,  have  used  the  method,  with  not  very 
encouraging  success.  Schroederf  identified  himself  with  the 
practice  of  enucleation  of  fibroids,  and  obtained  fair  results ; 
but  other  surgeons  have  not  been  prone  to  follow  his  example. 

Before  commencing  enucleation,  an  elastic  or  rope  tempo- 
rary ligature  should  be  carried  round  the  body  of  the  uterus 
below  the  fibroid  to  be  enucleated.  Incisions  are  then  made 
through  its  capsule,  circular  or  V-shaped  according  to  the 
degree  of  bulging,  and  arranged  so  as  to  leave  flaps  which, 
when  approximated,  will  completely  overlap  the  bed  from 
which  the  growth  is  enucleated.  If  the  flaps  do  not  fit  accu- 
rately, they  are  trimmed  down.  Rows  of  buried  sutures  are 
placed  from  the  bottom  of  the  wound  upwards,  in  succession, 
completely  approximating  the  sides  of  the  wound ;  finally  the 
peritoneal  surfaces  are  approximated  by  a  row  of  superficial 
sutures. 

Theoretically,  this  operation  of  enucleation  is  admissible ; 
but  practically,  its  mortality  is  high.    In  the  hands  of  Schroeder 

*  Archiv,  f.  Gyndh,  Bd.  iv.,  p.  340. 
t  Krankheiten  der  Weibl.  Sex.  Org.,  Leipzig,  1884. 


ENUCLEATION.  247 

himself,  its  chief  advocate,  i8  operations  were  followed  by  ii 
deaths — chiefly  from  haemorrhage  and  peritonitis ;  and  the 
results  of  other  surgeons  are  just  as  bad.  The  great  risk  is 
that,  when  the  inevitable  uterine  contraction  takes  place, 
haemorrhage  may  set  in;  the  almost  equally  great  danger  of 
peritonitis  would  seem  to  be  favoured  by  the  inclusion  of  dis- 
charges under  pressure  in  the  uterine  wound.  It  may  be  taken 
as  practically  true,  that  it  is  not  safe  to  leave  a  wound  through 
hypertrophied  uterine  tissue  with  no  more  perfect  guard  against 
hEemorrhage  than  a  non-contractile  ligature,  which  constricts 
uterine  fibre  as  well  as  vessels ;  and  even  less  safe  to  leave 
haemostasis  to  the  mercy  of  mere  compression  by  flaps  sutured 
over  the  wound. 


Hysterectomy,  total  or  partial,  for  Myoma. 


For  the  great  majority  of  cases  requiring  operation,  removal 
of  some  portion  of  the  uterus  is  either  necessary  or  expedient. 
And  of  this  majority,  the  greater  number  result  in  exposure  of 
the  uterine  cavity.  The  typical  operation  is  removal  of  the 
tumour  with  the  uterus  at  some  convenient  point  above  its 
attachment  to  the  vagina.  Complete  supra-vaginal  hysterec- 
tomy for  myoma  rarely  means  more  than  amputation  through 
the  cervix,  low  down. 

It  is  absolutely  impossible  to  give  a  description  of  hysterec- 
tomy for  myoma  which  shall  be  applicable  to  all  cases.  No 
two  cases  are  alike ;  and  the  variations  are  so  numerous  and  so 
diverse,  that  a  useful  classification  is  scarcely  feasible. 

Besides  the  ordinary  cutting  instruments,  the  surgeon  ought 
to  be  provided  with  at  least  two  trustworthy  clamps,  a  tempo- 
rary elastic  or  rope  ligature,  two  myoma  screws,  and  the  actual 

cautery.   Koeberle's 

well  -  known     serre- 

noeud    (Fig.    37)    is 

generally    admitted 

to   be  the  best  in- 
strument to  use  as  a 

clamp.     It  is  simple 

and  trustworthy. 

Tait  has  modified  it 

in  a  manner  which 

permits  of  more 

rapid  and  easy  fixa- 

tion  of  the  wire, 

without    interfering 

with    its    simpli- 
city and  efficiency. 

(Fig.  38.)    In  Tait's 

modification,  the 


Fig.  37. 


Fig.  38. 


KoebevWs  Serre-ncend. 
Half  size. 


Tait's  Modification 

of  Koeberle's  Serre-7tceud . 

Half  size. 


CLAMPS. 


249 


wires  are  simply  placed  in  recurved  V-shaped  claws,  which  bite 
the  more  firmly  as  traction  is  increased.  In  Koeberle's  original 
instrument,  one  end  of  the  wire  is  formed  into  a  loop,  which  is 
placed  over  the  button ;  the  other  end  is  fixed  by  twisting  or 
otherwise.  Keith  at  first  used  Koeberle's 
Ulilllili  I S"^  I  instrument ;  but  this  he  gave  up  in  favour 
of  a  very  large  thin  clamp,  which  he  finds 
causes  less  sloughing  than  a  wire. 

Some  form  of  in- 
strument for  tempo- 
rary compression  of 
the  pedicle  during 
manipulation,  and  be- 
fore placing  the  clamp 
in  position,  will  be 
found  of  great  assist- 
ance. Tait's  tempo- 
rary rope -compressor 
(Fig.  39)  seems  to  be 
the  most  convenient 
of  these  instruments. 
Pozzi's  elastic  tourni- 
quet (Fig.  40),  with 
self-acting  grip,  is  an 
excellent  instrument 
for  temporary  com- 
pression :  but  its 
action  is  not  so  rapid 
nor  so  powerful  as 
Tait's ;  and  it  is  open 
to  the  objection,  which 
may  be  urged  against  all  elastic  ligatures, 
that  it  is  liable  to  slip  over  the  stump 
when  the  tumour  is  cut  off.  The  rope 
texture  in  Tait's  instrument  is  preventive  against  slipping. 
A  few  feet  of  strong  soft  wire  should  be  held  in  reserve — 
piano-wire  serves  the  purpose  admirably ;  and  an  abundance^of 


Fig.  39. 

Tail's  Temporary 
Rope-Compressor.     Half 

size. 


Fig.  40. 

Pozzi's  Elastic  Tourni- 
quet. 


250  HYSTERECTOMY  FOR  MYOMA. 

the  strongest  Chinese  silk  ligatures  should  be  at  hand.  Other 
instruments  necessary  are :  strong  handled  needles  with  blunt 
points,  for  placing  ligatures  by  transfixion  ;  powerful  locking 
forceps,  straight  and  bent ;  and  needles  for  transfixing  and 
holding  the  pedicle  outside  the  abdominal  cavity. 

A  four-inch  incision,  extending  downwards  from  the  um- 
bilicus, is  first  made,  and  the  tumour  examined  as  far  as 
possible  with  the  hand;  we  note  the  position  of  the  broad 
ligaments,  the  ovaries,  and  the  tubes,  with  the  general  relations 
of  the  growth  to  the  uterus.  It  is  important  to  determine  the 
limits  of  the  bladder,  and  with  this  view  the  operation  should  be 
begun  with  the  bladder  full.  If  it  is  found  to  be  in  the  way,  it 
may  be  emptied  by  an  assistant  through  the  catheter.  The 
incision  is  prolonged  upwards  and  downwards,  as  far  as  is 
necessary  and  proper,  by  means  of  scissors  cutting  over  large 
flat  sponges,  and  guided  by  the  forefinger.  Bleeding  points  are 
secured  as  they  appear  by  catch-forceps. 

All  adhesions  to  the  parietes  in  front  having  been  separated 
by  tearing,  or  cutting  and  deligation,  one  or  more  screws  are 
twisted  into  the  tumour,  and  the  mass  lifted  out  of  its  bed. 
Considerable  force  may  be  necessary  for  this  manoeuvre  ;  but 
the  force  should  be  guided  and  regulated  by  the  hand  on  the 
under  surface  of  the  tumour,  to  make  certain  that  no  injury  is 
being  done  to  underlying  and  attached  structures.  Atmospheric 
pressure  often  accounts  for  much  of  the  difficulty  experienced 
in  delivering  such  tumours  ;  and  the  mere  insertion  of  the  hand, 
by  separating  contiguous  surfaces  and  permitting  the  entrance 
of  air,  may  lessen  this  difficulty.  Adhesions  to  omentum  or 
bowel  are  ligatured,  divided,  and  returned  as  they  appear. 
Frequently  the  tumour  comes  out  with  portions  of  intestine 
adherent  at  several  points  on  its  under  surface ;  these  adhesions 
are  caught  in  forceps,  divided,  and  ligatured  afterwards. 
The  tumour  being  completely  delivered,  several  large  flat 
sponges  are  placed  in  the  cavity  over  the  bowels.  If  the 
patient  is  sick  or  straining  and  the  bowels  tend  to  protrude, 
a  few  sutures  may  at  once  be  inserted  in  the  upper  portion  of 
the  abdominal  wound. 


FIXING   THE  CLAMP.  251 

A  minute  examination  of  the  tumour  and  its  connections 
is  now  mstituted.  The  position  of  the  bladder  is  first  ascer- 
tained. Keith  has  met  with  the  bladder  nearly  as  high  as  the 
umbilicus,  so  that  it  had  to  be  dissected  downwards :  this 
happens  more  especially  when  the  tumour  dips  deeply  into  the 
pelvis,  and  where  the  broad  ligaments  are  much  opened  up. 
On  the  tumour  aspect,  the  separation  of  the  bladder  is  not 
often  difficult.  In  every  case,  diagnosis  of  the  position  of  the 
bladder,  and  separation  of  it  from  tumour  and  parietes,  is  much 
facilitated  if  the  viscus  be  moderately  distended.  When  it  is 
sufficiently  freed,  it  may  be  emptied  through  the  catheter.  If 
the  dissection  has  to  be  carried  down  to  the  base  of  the 
bladder,  especial  care  must  be  taken  to  avoid  injury  to  the 
ureters.  It  need  scarcely  be  said  that  all  manipulations  involv- 
ing the  bladder  must  be  carried  out  with  great  care. 

Supposing  that  the  relations  of  the  bladder  to  parietes  and 
to  uterus  are  normal,  and  that  the  tumour  has  not  grown 
between  the  folds  of  the  broad  ligament,  and  does  not  lie  deep 
in  the  pelvis  ;  and  supposing,  further,  that  the  direction  of  the 
growth  of  the  mass  has  been  mainly  towards  the  abdominal 
cavity,  and  that  the  neck  and  part  of  the  body  of  the  uterus  are 
but  little  enlarged,  we  have  to  deal  with  the  simplest  of  all 
varieties  of  hysterectomy  for  m3'oma.  Irt«uch  a  case,  the  opera- 
tion may  be  at  once  completed  by  fixing  the  wire  clamp  at  a 
suitable  place  around  or  near  to  the  neck  of  the  uterus,  and  the 
tumour  cut  away  above  it.  The  wire  includes  in  its  grasp 
round  ligaments  and  broad  ligaments,  as  well  as  uterus,  and 
the  ovaries  and  tubes  are  also  included  in  the  amputation. 
Enucleation  is  not  called  for ;  the  peritoneum,  intact,  surrounds 
the  whole  of  the  tissues  included  in  the  clamp.  Two  pedicle 
needles  are  passed  through  the  stump,  above  the  constricting 
wire,  and  their  broad  ends  are  made  to  rest  at  convenient  points 
on  the  abdominal  parietes.  The  stump  is  fixed  in  the  bottom 
of  the  parietal  wound,  the  abdominal  cavity  is  cleansed,  the 
wound  is  sutured,  and  the  operation  is  finished. 

But  few  operations  are  of  this  simple  nature.  The  pedicle 
must  be  manufactured  or  isolated,  after  a  more  or  less  difficult 


252  HYSTERECTOMY  FOR   MYOMA. 

process  of  enucleation  or  dissection.  In  the  worst  cases  this 
is  a  most  tedious  and  delicate  operation,  severely  testing  the 
surgeon's  practical  knowledge  and  technical  skill.  A  perusal  of 
the  detailed  cases  of  our  most  experienced  operators,  such  as 
those  of  Keith  or  Schroeder,  while  emphasizing  the  fact  that  no 
two  operations  are  alike,  can  scarcely  fail  to  convince  the 
reader  that  the  details  are,  after  all,  very  similar.  It  seems 
to  me  that  Schroeder's  magnificent  operations  have  suffered 
a  little  from  the  operator's  desire  to  carry  out  a  principle — 
enucleation  with  salvation  of  uterus  and  appendages.  Keith,  on 
the  other  hand,  has  evidently  no  preconceived  principle  whatever : 
relying  on  his  own  experience,  he  attacks  off-hand  every  compli- 
cation as  it  arises,  with  the  simple  aim  of  curing  his  patient. 
And  Keith  is  right.  Every  consideration  whatsoever  must  give 
way  in  the  face  of  the  risks  of  life  and  death.  Schroeder's 
work  is  valuable,  as  teaching  us  how  to  enucleate ;  Keith's  is 
still  more  valuable,  by  showing  to  what  extent  enucleation  may, 
with  best  results  to  the  parient,  be  carried.  The  result  of  their 
practice  and  of  that  of  others  has  shown  that,  while  enucleation 
from  peritoneal  and  fibrous  investments  is  often  necessary  and 
proper,  enucleation  from  uterine  tissue  is  rarely  necessary,  and 
still  more  rarely  proper. 

Schroeder's  work,  though  it  is  not  antecedent  to  Keith's,  is 
worthy  of  special  description.  His  purpose  was,  to  spare  the 
uterus  and  its  appendages  as  much  as  possible.  His  mode  of 
operating  may  be  given  in  his  own  words. ''^'  A  case  is  supposed 
in  which  "the  uterus  is  found  enlarged  by  an  interstitial  fibroid, 
dislocating  upwards  the  appendages  on  both  sides.  In  this  case 
it  is  not  possible  to  place  the  India-rubber  ligature  around  the 
cervix  :  besides,  there  is  no  pedicle  ;  the  first  thing  therefore,  is 
to  form  one.  For  this  purpose,  I  sever  the  appendages  by  first 
doubly  ligaturing  the  infundibular  pelvic  ligament,  with  its 
spermatic  vessels,  and  dividing  between  these  ligatures ;  then 
by  repeating  the  same  process  with  the  round  ligament,  which 
generally  is  found  to  be  in  a  hyperplastic  state.  After  this  has 
been  executed  on  both  sides,  it  is  easy  to  separate  the  tumour 
*  Brit.  Med.  Joiirn.,  1883,  ii.,  p.  714. 


SCHROEDER'S    OPERATIONS.  253 

from  the  surrounding  tissue   without  causing  any  considerable 
haemorrhage ;     and   now   the    India-rubber    ligature   is   placed 
around   its   base.       The   tumour   is   then   cut  away   with   the 
uterus    above   this    ligature.     Care    must  always  be  taken   to 
catch  the  stump  in  a  vulsellum  as  soon  as  part  of  the  tumour 
is  divided  ;  for  this  prevents  the  rubber  ligature  from  slipping 
off.     After  thus  securing  the  stump,  the  remaining  part  of  the 
tumour  is  cut  away.     Next,  the    cavity  of   the    uterus   or  the 
cervical    canal    is  cauterised    with  a  ten  per  cent,  solution  of 
carbolic  acid,  in  order  to  destroy  any  infectious  germs  that  may 
be   present.     .     .     .     The  denuded  surfaces  of  the  stump  are 
first  united  in  the  depth  near  to  the  mucous  membrane  of  the 
uterus  ;  these  sutures  are  covered  up  by  several  rows  of  other 
sutures,  uniting  the  walls  of  the  stump  ;  finally,  the  peritoneum 
is  pulled  over  the  stump,  and  attached  to  it  and  to  the  peri- 
toneum of  the  other  side  by  a  line  of  closely-placed    stitches. 
On   the   sides  of  the   stump    at    the  spots  on  which  the  large 
blood-vessels  have  been  divided,  and  on  which  the  peritoneum 
covers  the  stump  only  loosely,  the  tissues  are  firmly  fastened  to 
the  stump  by  a  separate  deep  suture.      After  removal  of  the 
India-rubber  ligature,  the  stump  is  seen  with  a  smooth  covering 
of  the  peritoneum  united  by  a  neat  row  of  sutures.     At  each 
side  of  the  stump,  the  divided,  but  not  stitched,  broad  ligaments 
are  visible  ;  in  front  we  have  the  ligatured  round  ligament,  and 
towards    the   pelvic  wall,  the   ligatured    spermatic  artery,  &c. 
There  is  no  dragging  on  the  tissue  whatever  around  the  stump, 
and  the  peritoneal  covering  is  perfectly  smooth.     Any  haemor- 
rhage  occurring  after  removal  of  the  India-rubber  ligature  is 
easily  stopped   by  putting  a  few   more   stitches   at   the   spots 
whence  it  comes. 

"  The  difficulties  of  the  case  become  very  numerous  when  we 
have  to  remove  a  fibroid  developed  at  the  lower  part  of  the 
uterus  and  extending  into  the  cellular  tissue  of  the  pelvis.  The 
uterus  is  sometimes  dragged  upwards  on  one  side  so  far  that  it 
is  impossible  to  reach  the  os  with  the  finger.  In  such  cases 
I  again  ligature  the  appendages  as  explained  above,  and  I  then 
enucleate  the  tumour  out  of  the  pelvic  cellular   tissue.     This 


254  HYSTERECTOMY  FOR   MYOMA. 

latter  manipulation  is  generally  very  easy.  Tumours  firmly 
located  in  the  pelvis  are  thus  made  free  from  the  surrounding 
tissue,  and  appear  attached  only  to  the  cervix.  The  India- 
rubber  ligature  is  then  applied  around  the  cervix,  the  tumour  is 
cut  off  above  it,  and  the  stump  stitched  up,  according  to  the 
principles  described  above.  There  remains,  however,  a  cavity 
out  of  which  the  tumour  has  been  enucleated.  This  can  be 
treated  in  different  ways.  If  I  do  not  expect  a  very  abundant 
secretion  from  it,  I  leave  the  walls  of  the  cavity  simply  to  close 
upon  each  other,  and  drop  the  whole  into  the  abdomen.  In 
other  cases,  I  insert  a  drainage  tube  from  the  cavity  into  the 
vagina,  and  close  the  wound  towards  the  abdominal  cavity  by 
stitching  the  peritoneum  over  it.'.' 

Schroeder  then  speaks  of  the  occasional  necessity  of  dis- 
secting the  bladder  from  the  tumour,  and  further  describes  an 
operation  for  removing  a  fibroid  situated  low  down  in  the 
posterior  lip.  At  the  time  of  writing,  Schroeder's  mortality  was 
30  per  cent.;  just  before  he  died,  it  was  said  to  have  diminished 
to  about  15  per  cent.  This  death-rate  is  too  high;  and  probably 
the  exact  following  of  Schroeder's  method  of  operation  has  died 
with  him. 

With  Schroeder's  description  we  may  profitably  compare  the 
following  description  of  operations  by  Keith.* 

The  first  case  was  that  of  an  umarried  woman  aged  28. 
"  The  first  incision  measured  twelve  inches :  it  terminated  four 
inches  above  the  pubes,  so  as  to  avoid  the  bladder,  which  was 
known  to  be  elevated  on  the  tumour.  On  the  right  side,  the 
broad  ligament  rose  as  high  as  the  crest  of  the  ilium.  The  left 
broad  ligament  was  largely  spread  over  the  half  of  the  tum6ur 
as  high  up  as  the  ribs.  The  opening  was  then  enlarged  to 
22  inches,  and,  by  dint  of  hard  pushing  and  patience,  the  huge 
mass  was  slowly  moved  forwards  as  far  as  its  connections  on  the 
left  side  would  permit.  The  right  ovary  was  easily  seen.  On 
searching  for  the  left,  it  was  found  to  be  transformed  into  a  long, 
tense,  umbihcal-like  cord,  seven  or  eight  inches  in  length.    Here 

*  Cases  vii.  and  xxxvii.  in  Hysterectomy  for  Fibrous  Tumours  of  the  Uterus. 
Edinburgh,  1885. 


KEITH'S  OPERATIONS.  255 

and  there  along  this  tense  band  were  several  small  cysts.     It 
was  so  embedded  in  the  tumour  that  it  could  never  have  been 
removed.     The  right  broad  ligament  was  transfixed  by  soft  iron 
wires,  secured,  and  divided ;  all  bleeding  from  the  tumour  side 
was  prevented  by  a  series  of  strong  locking  forceps.    The  fibroid 
was  now  more  easily  dealt  with.     It  was  drawn  forwards,  so  as 
to  put  on  the  stretch  its  enormous  connection  on  the  left  side. 
About  a  dozen  locking  forceps,  lo  inches  in  length,  were  now 
applied  to  the  broad  ligament,  before  and  behind.     The  whole 
was  then  cut  downwards,  and  the  mass  enucleated  as  low  as 
possible.     A  strong  soft  iron  ligature  embraced  the  base,  which 
was  of  great  thickness.     The  tumour  was  then  cut  away,  the 
stump  showing  a  section  of  the  cervix  in  the  centre.    The  forceps 
were  removed  one  by  one,  and  all  the  bleeding  vessels  separately 
tied.     Some  of  these  were  large,  and  one  threw  blood  over  the 
assistant's   head.     There   was   much   trouble   in   finding   some 
bleeding  points  among  the  cellular  tissue  of  the  huge  gap  now 
left.     The  haemorrhage  was  mostly  venous.     All  present  could 
see  that  this  condition  was  full  of  danger,  and  that  secondary 
haemorrhage  into  this  loose  tissue  was  not  one  of  the  smallest 
risks  of  this  operation.    When  all  oozing  seemed  to  have  ceased, 
the  stump  (the  thickness  of  the  leg)  and  the  end  of  the  right 
broad  ligament  were  secured,  with  much  tension,  outside ;    a 
glass  drainage  tube  was   fixed   in  above  the  stump,  and  the 
wound  closed  by  forty  silk  sutures.     The  operation  lasted  one 
hour  and  three-quarters.      After  much  blood  and  serum  had 
escaped  from  the  tumour,  its  weight  was  42  lbs."     The  patient 
recovered. 

The  second  case  selected  was  that  of  an  unmarried  woman 
aged  34.  *'  The  incision  extended  from  five  inches  above  the 
umbilicus  to  two  inches  above  the  pubes.  When  exposed,  the 
tumour  was  deeply  congested  and  very  vascular.  On  intro- 
ducing the  hand,  the  tumour  was  found  to  extend  very  high  up. 
It  was  in  contact  with  the  liver,  pushing  both  it  and  the 
diaphragm  upwards,  and  there  were  extensive  adhesions  above 
everywhere.  The  slightest  touch  of  the  hand  on  the  diaphragm, 
in  making  this  examination,   caused  respiration  invariably  to 


256  HYSTERECTOMY  FOR  MYOMA. 

stop  at  once.  It  was  impossible  to  get  out  the  tumour.  The 
incision  was  then  enlarged  up  as  far  as  it  would  go.  This 
exposed  adherent  omentum  and  some  long  broad  adhesions 
coming  from  above,  as  well  as  some  parietal  adhesions.  The 
tumour  was  fixed  too  high  up  under  the  sternum  to  be  brought 
out  in  any  way.  It  was  then  pulled  out  of  the  pelvis,  and  by 
placing  several  pairs  of  enormous  locking  forceps  round  the 
ligaments  and  base,  the  tumour  was  got  out  first  from  below. 
Then,  by  introducing  two  hands  on  either  side  the  upper  portion 
was  suddenly  dislodged,  and  it  appeared  with  the  whole  of  the 
stomach  attached  to  its  upper  and  back  part.  The  omentum, 
containing  enormous  vessels,  was  spread  over  the  upper  third  of 
the  tumour  all  round,  also  a  quantity  of  adherent  mesentery  and 
intestine.  No  one  who  had  examined  the  case  had  the  slightest 
idea  of  this  mass ;  at  least  one-third  of  the  whole  tumour  was 
concealed  by  the  ribs.  All  these  adhesions  were  separately  tied 
as  quickly  as  possible,  a  very  large  number  of  ligatures  being  left 
in.  The  part  of  the  tumour  which  had  felt  like  a  large  kidney 
before  operation  was  entirely  covered  by  adherent  ascending 
colon,  and  was  shelled  out  of  its  cellular  attachments.  This 
adhesion  gave  the  most  trouble.  The  worst  bleeding,  however, 
came  from  above,  partly  from  the  vascular  wall  and  partly  from 
the  long  adhesions  that  came  down  from  the  diaphragm  under 
the  sternum.  In  the  upper  part  of  the  incision  there  were  so 
many  vessels  to  tie,  that  many  carbolised  silk  ligatures  were 
used.  The  wound  was  closed  by  thirty-one  deep  sutures,  besides 
superficial  ones.  The  incision  above  the  umbilicus  was  longer 
than  below  it.  Operation  lasted  one  hour  and  five  minutes.  A 
drainage  tube  was  left  in.  The  upper  part  of  the  tumour  was 
broader  than  the  lower.  It  weighed  i6  lbs."  The  patient 
recovered. 

I  venture  to  add  one  case  from  my  own  experience  which 
has  some  points  of  special  interest. 

The  patient  was  an  unmarried  woman  of  forty.  The  opera- 
tion was  in  a  sense  exploratory,  though  on  the  whole  the 
diagnosis  was  between  ovarian  cystoma  and  fibro-cyst  of  the 
uterus.     It  was  a  very  soft  fibroid,  full  of  enormous  vascular 


SPECIAL  OPERATIONS.  257 

channels,  which  made  the  tumour  fluctuate.  I  had  decided  to 
remove  the  appendages,  although  the  growth  was  perhaps  too 
large  to  promise  full  benefit  from  this  operation.  The  left  ovary 
was  pulled  up  with  some  difficulty,  and  with  it  came  enormous 
coils  of  dilated  veins  which  looked  as  large  as  the  small  intestine. 
A  forceps  placed  on  the  pedicle  of  the  ovary  included  parts  of 
the  walls  of  more  than  one  of  these  veins ;  and  they  were  so 
closely  set  that  transfixion  would  have  been  impossible  with- 
out wounding  them.  The  right  ovary  could  not  be  found  ;  and 
though  the  whole  uterus  was  removed  and  carefully  examined,  it 
was  never  found.  In  the  meantime  blood  came  welling  out  of  the 
pelvis,  and  was  found  to  originate  from  the  veins  grasped  in  the 
blades  of  the  forceps.  Several  large  locking  forceps  were  placed 
on  those  veins  below  the  bleeding  point ;  but  each  grasp  of  the 
blades  seemed  to  tear  the  friable  tissue  and  cause  more  bleeding. 
The  tumour  was  delivered,  and  the  bleeding  from  the  veins  in 
the  left  broad  ligament  was  more  easily  controlled  when  they  were 
put  on  the  stretch.  Finally,  a  few  ligatures  were  placed  around 
them  by  an  aneurism  needle  carefully  pushed  through  the  cellular 
tissue,  and  the  broad  ligament  cut  away  from  the  uterus.  The 
base  of  the  bladder  dipped  down  in  a  deep  sulcus  between  the 
uterine  body  and  a  separate  growth  as  large  as  the  fist,  and 
required  to  be  carefully  separated  by  dissection.  The  fibroid  on 
the  right  side  dipped  down  in  a  curious  manner  under  the  right 
ureter,  and  here  enucleation  had  to  be  carried  out  with  great  care. 
This  state  of  matters,  combined  with  the  absence  of  uterine 
appendages  on  the  right  side,  suggested  the  possibility  of  there 
being  some  congenital  malformation  of  the  uterus — possibly  it 
was  unicorned.  Below  the  overlapping  fibroid  was  the  only  site 
suitable  for  applying  the  clamp,  and  this  lay  so  low  down  that  it 
seemed  impossible  to  treat  the  pedicle  extra-peritoneally.  How- 
ever, a  wire  clamp  was  applied  and  tightened,  and  the  tumour 
was  cut  away  above  it,  exposing  ine  uterine  cavity.  As  blood 
welled  up  rather  freely  from  the  pedicle,  the  clamp  was  tightened 
till  considerable  force  was  required  to  turn  the  screw.  Still  the 
blood  flowed  from  the  cut  surface,  and  now  the  wire  was 
crushing  up  the  uterine  fibres  and  deeply  embedded.    At  the  next 

18 


258  HYSTERECTOMY  FOR   MYOMA. 

turn  of  the  screw  the  clamp  broke.  (I  purposely  avoid  naming 
the  clamp  used,  as  the  fault  lay  with  the  instrument  maker,  and 
not  with  the  inventor.)  No  forceps  made  could  be  of  any  use 
here.  A  very  thick  double  silk  ligature  was  rapidly  cast  round 
the  pedicle,  and  tied  as  tightly  as  possible.  Still  bleeding  went 
on.  Then  double  transfixion  ligatures  were  placed  and  tied ;  then 
the  actual  cautery  was  used  ;  but  still  there  was  bleeding,  though 
not  so  free.  Finally,  a  silk  ligature  in  three  interlocking  loops 
was  carried  through  the  whole  pedicle  and  firmly  tied  ;  this  left 
only  very  slight  oozing.  A  drainage  tube  was  inserted,  and  the 
abdomen  closed  over  the  pedicle.  The  operation  lasted  a  little 
over  an  hour.  Nearly  half  a  pint  of  blood  was  removed  by 
suction  through  the  tube  in  the  first  twenty-four  hours  ;  at  the 
end  of  a  week,  only  a  little  bloody  serum  could  be  sucked  out, 
and  the  tube  was  then  removed.  Three  days  later  the  tem- 
perature rose,  and  tympanites  appeared.  The  abdomen  was 
re-opened  and  washed  out,  and  the  drainage  tube  re-inserted.  The 
pedicle  sloughed  and  came  away;  and  the  patient  recovered,  with 
an  opening  between  the  vagina  and  the  pubes  through  which  mat- 
ter discharged.  After  four  months  the  fistula  closed.  By  vaginal 
examination  not  a  particle  of  uterine  tissue  can  be  detected. 

The  study  of  a  few  such  cases  as  these— and  many  such  have 
been  recorded — is  more  instructive  than  much  generalised  de- 
scription. They  show  that  the  surgeon  who  begins  to  remove  a 
large  uterine  fibroid  must  be  prepared  to  treat  off-hand  compli- 
cations of  the  most  difficult  and  even  alarming  character. 
Extensive  adhesions  may  be  found  with  any  abdominal  organ — 
even  with  the  stomach  and  liver;  they  may  even  arise  from 
the  diaphragm.  Enucleation  may  have  to  be  made,  not  only 
from  between  the  folds  of  the  broad  ligament,  but  from  under 
the  greater  part  of  the  pelvic  and  some  portion  of  the  abdominal 
peritoneum.  Keith,  in  one  case,  left  ver}'  little  peritoneum 
behind  on  the  parietes  ;  the  intestines  in  many  places  lay  in 
contact  with  the  bared  muscles.  And  then  the  veins  in  the 
tumour  capsule  and  in  the  broad  ligaments  may  be  so  enormous 
and  so  thin-walled  that  ordinary  surgical  measures  may  be 
almost  ineffectual  to  stop  bleeding  from  them.     The  comfort  of 


DETAILS  OF  OPERATION.  259 

a  temporary  elastic  or  rope  compressor  in  these  circumstances 
can  scarcely  be  exaggerated. 

A  few  special  points  may  be  summarised  : 

In  cases  where  the  growth  of  the  tumour  is  mainly  in  the 
fundus  and  towards  the  abdominal  cavity,  and  where  the  vessels- 
in  the  broad  ligament  are  neither  large  nor  thin-walled,  the  wire 
clamp  may  be  at  once  placed  around  the  cervix,  and  the  tumour 
cut  away. 

Where  the  whole  uterus  is  enlarged  and  the  uterine  cornua, 
with  the  round  ligaments,  tubes,  and  ovaries,  retain  their  normal 
relations,  the  broad  ligaments  being  on  the  stretch  between  the 
pelvis  and  the  tumour,  it  will  be  wise  to  divide  the  broad 
ligaments  at  some  convenient  point  high  up,  and  ligature  them 
separately.  This  division  frees  the  tumour  and  permits  of  its 
being  drawn  farther  out  of  the  abdominal  cavity,  so  that  the 
clamp  may  be  placed  lower  down.  Large  or  thin-walled  vessels 
lying  in  the  broad  ligaments  should  be  secured  by  ligature  and 
not  included  in  the  wire  of  the  serre-nceud.  Haemorrhage, 
occurring  during  the  separation  of  the  pedicle,  frequently  starts 
from  these  vessels.  This  fact  alone  would  make  me,  in  every 
case  where  the  broad  ligaments  can  be  isolated  and  ligatured, 
treat  them  by  intra-peritoneal  deligation,  while  the  pedicle 
proper  is  treated  extra-peritoneally. 

Where  the  tumour  grows  from  the  side  or  sides  of  the  uterus, 
the  folds  of  the  broad  ligament  are  opened  up,  the  whole  pelvic 
peritoneum  may  be  elevated,  and  some  portion  of  the  abdominal 
peritoneum  may  be  removed  from  the  posterior  wall.  In  such 
cases,  extensive  enucleation  may  be  called  for,  and  large  raw 
surfaces,  or  rather  cavities,  may  be  left  behind.  The  edges  of 
the  peritoneal  wound  need  not  be  sutured — they  will  fall  into^ 
apposition ;  but  drainage  must  be  efficient. 

In  every  case  where  an  adhesion  is  separated  and  tied,, 
a  locking  forceps  should  be  placed  on  the  site  of  its  attachment 
to  the  tumour.  No  wound  of  the  capsule  should  be  made  until 
a  compressing  ligature  has  been  carried  around  the  base  of  the 
tumour.  Haemorrhage  from  the  capsule  of  uterine  myoma  may 
be  very  free. 

18  * 


260  HYSTERECTOMY  FOR  MYOMA. 


TREATMENT    OF    THE    PEDICLE    IN    HYSTERECTOMY. 

This,  the  most  important  detail  in  the  operation,  requires 
separate  consideration. 

There  are  three  methods  of  treating  the  pedicle;  intra- 
peritoneal ;  extra-peritoneal  ;  and  mixed,  or  partly  intra- 
peritoneal and  partly  extra-peritoneal. 

Intra-pcritoneal  Treatment  of  the  Pedicle. — All  surgeons  aim  at 
complete  intra-peritoneal  treatment  of  the  pedicle  in  hysterec- 
tomy for  fibroids ;  and  there  are  few  surgeons  of  experience  in 
the  operation  who  have  not  tried  it.  It  may  at  once  be  said  that 
very  few  of  those  who  have  tried  the  intra-peritoneal  treatment 
are  satisfied  with  it — at  least,  as  at  present  performed.  Some 
cases  are  more  suitable  for  this  plan  than  others  ;  in  many,  it  is 
either  impracticable  or  unsound.  Excessive  thickness  of  the 
parietes  has,  in  one  case,  compelled  me  to  adopt  the  intra- 
peritoneal method. 

The  advantages  of  this  mode  of  treating  the  pedicle  are 
self-evident.  The  disadvantages  are :  the  large  size  of  the 
pedicle,  its  vascularity,  its  tendency  to  shrink,  and  its  liability 
to  undergo  sloughing. 

In  1874  Kaltenbach  proposed  intra-peritoneal  treatment  for 
small  pedicles,  with  suture  of  the  edges  of  the  wound  in  the 
uterus  and  of  the  broad  ligaments.  Hegar*  about  the  same 
time  employed  this  plan  with  success.  In  1877  Kleebergf 
suggested  the  elastic  ligature,  and  proved  its  harmlessness  in 
the  abdominal  cavity  by  experiments.  In  1878  Czernyj  put 
the  idea  into  practice  by  leaving  the  elastic  ligature  surrounding 
the  pedicle  inside  the  abdomen.  Wells,  Koeberle,  Pean,  and 
others  about  this  time  recorded  cases  of  intra-peritoneal  treat- 
ment of  the  pedicle  chiefly  by  multiple  ligatures,  but  with  no 
very  encouraging  success.  Olshausen,  Fritsch,  and  Leopold 
had  fair  results  with  the  elastic  ligature ;  but  Martin,  Tauffer, 
.and  a  few  others  somewhat  discredited  this  method  by  showing 

*  Operat.  Gyniik.,  Stuttgart,  1880,      t  St.  Petersburg  med.  Woch.,  1877  and  1879. 
I  Centralbl.  f.  Gyndk.,  1879,  p.  519. 


TREATMENT  OF  PEDICLE.  261 

that  it  sometimes  caused  sloughing  of  the  pedicle,  or  suppu- 
ration and  septicaemia. 

By  far  the  most  important  systematic  attempt  to  arrive  at  a 
trustworthy  intra-peritoneal  treatment  of  the  pedicle  was  made 
by  Schroeder.*  Schroeder's  plan,  already  described,  is  essentially 
multiple  ligature  of  bleeding  points,  and  deep  and  superficial 
suture  of  the  wound  in  the  uterus.  He  began  by  the  application 
of  a  temporary  elastic  ligature  near  the  neck  of  the  uterus,  then 
separately  ligatured  the  vessels  in  the  broad  ligament  which 
supply  the  uterus,  and  finally  dealt  with  the  uterine  wound. 
Martin  advocates  Schroeder's  plan,  with  the  substitution  of  silk 
for  catgut  as  material  for  ligature.  To  the  mucous  membrane 
of  the  exposed  cavity  carbolic  acid,  or  corrosive  sublimate,  or 
the  actual  cautery,  is  applied  to  cause  disinfection.  Leopold, 
von  Antal,  Thiriar,  Olshausen,  Fischer,  Marey,  and  many  others, 
have  introduced  unimportant  modifications. 

The  outcome  of  the  recorded  experience  of  the  intra- 
peritoneal treatment  of  the  pedicle  may  be  shortly  summarised 
as  follows.  The  elastic  ligature  overdoes  compression,  tending 
to  cause  suppuration,  sloughing,  or  even  septicaemia.  All 
modes  of  ligation  in  mass  with  non-elastic  material  are  unsafe, 
on  account  of  the  shrinkage  of  the  uterine  fibre.  Multiple 
ligation,  or  ligation  in  detail  of  vessels  in  the  broad  ligaments 
and  in  the  stump,  is  less  dangerous,  but  still  not  satisfactory. 

This  plan  is  made  more  safe  by  superadding  deep  and  super- 
ficial suturing  of  the  uterine  wound.  As  additional  precautions 
against  haemorrhage,  the  stump  has  been  seared  with  the  actual 
cautery,  and  it  has  been  soaked  with  powerful  haemostatics  ;  but 
the  results  have  even  then  not  been  fully  satisfactory. 

Extra-peritoneal  Treatjuent  of  the  Pedicle. — This  is  the  original 
plan  of  Kimball,  Wells,  and  Koeberle ;  and  it  still  remains  the 
best.  Kimball  used  the  actual  cautery,  with  fixation  in  the 
inferior  angle  of  the  wound.  Wells  transfixed  the  pedicle  with 
two  strong  needles ;  below  these  he  placed  a  ligature,  and  fixed 

*  Zeitschr.  f.  Get.  tind  Gyncik.,  1881,  p.  213,  and  1883,  p.  204;  and 
Brit.  Med.  Journ,,  loc.  cit. 


262 


HYSTERECTOMY  FOR  MYOMA. 


the  stump  in  the  parietal  wound.  In  1864  Koeberle  introduced 
his  wire  clamp  for  the  treatment  of  the  pedicle ;  and  this 
instrument,  with  unimportant  modifications,  and  his  plan,  still 
continue  in  favour.  Many  other  varieties  of  extra-peritoneal 
treatment  have  been  invented,  and  many  instruments  have  been 
introduced.  In  this  connection  the  names  of  Pean  and  Cintrat 
deserve  mention  for  their  wire  clamps ;  and  those  of  Baker  Brown, 
Keith,  Kiwisch,  and  Wells,  for  their  special  unyielding  clamps. 
Avoiding  detailed  historical  description,  we  may  confine  our 

attention  to  the  three  most  im- 
portant modes  of  extra-peri- 
toneal treatment  of  the  pedicle 
at  present  in  vogue  :  by  the 
clamp;  by  the  elastic  ligature; 
and  by  the  wire  constrictor. 

Keith,  so  far  as  I  know,  is 
the  only  highly  successful 
operator  who  uses  the  clamp. 
It  is  a  special  instrument, 
made  very  large  and  thin. 
(Fig.  41.)  He  says:  "I  have 
not  found  sloughing  take  place 
to  the  extent  that  it  does  when 
a  single  wire  merel}^  embraces 
the  pedicle ;  the  parts  are  more 
spread  out  in  the  clamp,  and 
there  is  not  nearly  the  amount 
of  puckering  of  the  soft  parts 
that  there  is  when  a  wire  is 
used.  A  mass,  as  thick  as  the 
wrist,  can  be  squeezed  into  a 
loop  an  inch,  or  three-quarters 
of  an  inch,  in  diameter; 
whereas,  with  a  large  clamp  there  is  no  great  pressure  on 
any  one  part  below.  The  pressure  of  the  wire  does  not 
act  simply  on  the  constricted  portion,  but  exerts  its  influence 
to   some    distance    below  the   constriction.      .      .      .      Before 


Fig.  41. 

Keith's  Clamp  for  Hysterectomy. 
One-third  size. 


ELASTIC    LIGATURE. 


263 


applying  the  clamp,  it  is  better  to  draw  all  the  parts  gently 
together  by  a  thick  silk  ligature  or  by  a  soft  wire.  This 
prevents  a  too  great  spreading  out  of  the  parts  between  the 
blades,  which  would  render  the  closing  of  the  wound  around 
the  clamp  somewhat  troublesome."  Keith  applies  freely  to  the 
stump  a  saturated  solution  of  perchloride  of  iron  in  glycerine, 
and  then  dries  it  off;  after  this,  plenty  of  iodoform  and  salicylic 
wool.     The  cervical  canal  is  scraped  out  and  disinfected. 


Fig. 


42. 


(Hegar 

AND      KaLTENBACH.) 

Needle  for  carrying:; 

elastic  ligature  through 

Pcdicli, 


The  elastic  hgatuve 
has  many  suppor- 
ters; Olshausen, 
Martin,  Sanger,  and 
Hegar,  being  among 
the  chief.  It  may  be 
applied  either  as  an 
encircling  ligature, 
around  the  whole  ; 
or  as  a  transfixing 
ligature,  embracing 
the  pedicle  in  halves; 
or  as  a  double  liga- 
ture, encircling  and 
transfixing.  For  ap- 
plying the  ligature 
around  the  pedicle, 
the  ingenious  in- 
strument of  Pozzi 
(Fig.  40)  will  be 
found  valuable. 
With  it,  any  requi- 
site amount  of  ten- 
sion can  readily  and 
rapidly  be  applied, 
and  the  instrument 
automatically  keeps 
up  whatever  tension 


Fig.  43. 

(Hegar   and  Kaltenbach.) 

To  show  closure  of  Abdominal 

Wound  (a)  ; 

and  treatment  of  Pedicle  by 

elastic  ligature  (b). 


264 


"'HYSTERECTOMY  FOR  MYOMA. 


is  put  on.  For  carrying  the  ligature  through  the  pedicle  Hegar 
has  invented  a  transfixing  needle.  (Fig.  42.)  It  is  composed  oi 
two  parts — -a  sharp  conical  piercing  point,  which  screws  off; 
and  a  hollow  tubular  portion  split  along  the  side,  into  which  the 
ligature  is  drawn  in  a  loop.  The  knot  made  in  the  elastic  ligature 
is,  if  necessary,  finally  secured  by  surrounding  it  with  a  strong 
silk  ligature.  Terrillon  and  Trelat  have  quite  recently  introduced 
ingenious  instruments  for  the  application  of  the  elastic  ligature. 
Hegar  lays  particular  stress  on  the  mode  of  closing  the  abdo- 
minal wound  b}^  peritoneal  suture,  and  on  the  fixation  of  the  ped- 
icle in  its  lower  angle.  (Fig.  43.)  To  prevent  retraction  where 
the  pedicle  is  short,  pedicle  needles  should  be  pushed  through  it. 
The  elastic  ligatures  are  cut  away  about  the  eighth  or  tenth  day. 

The  wire-constrictor  remains  the  favour- 
ite instrument  with  most  operators ;  and 
Koeberle's  simple  instrument,  or  some  mod- 
ification of  it  such  as  Tait's,  is  generally 
acknowledged  to  be  the  best.  Its  applica- 
tion is  exceedingly  simple.  In  most  cases, 
the  wire  is  placed  below  a  temporary  con- 
strictor of  rope  or  elastic.  With  Tait's  in- 
strument the  two  ends  of  the  wire  are  simply 
pulled  tightly  around  the  pedicle,  and  hooked 
into  the  claws  on  the  sliding  screw.  With 
Koeberle's  original  instrument,  or  rather  with 
Bantock's  modification  of  it,  one  end  islooped 
on  to  a  button  on  the  screw,  and  the  other  is 
pulled  over  the  same  button  and  fixed  there. 
The  instrument,  being  left  attached,  is  placed 
so  that  it  lies  fl.atly  on  the  abdominal  wall, 
pointing  upwards  and  to  one  side.  Koeberle 
himself  uses  two  of  his  instruments,  each 
encircling  half  the  pedicle.  Strong  pedicle 
needles    (Fig.  44)    are  pushed    through  the 

pedicle  above   the  level   of  the  wire,   their   ^'"^^'  M  Transfixing 

Pedicle 
broad   ends   restmg  on   the   panetes.     The        in  Hysterectomy. 

needles    should    always   be   inserted    before  Half  siz'. 


Fig. 


44. 


TREATMENT  OF  THE  PEDICLE  265 

the  tumour  is  cut  away,  to  prevent  retraction  of  tissues  after- 
wards. 

In  those  cases  where  the  pedicles  of  the  broad  ligaments  are 
left  inside — and  such  will  form  the  majority — it  may  be  neces- 
sary to  pull  together  around  the  pedicle  the  detached  peri- 
toneum, so  that  the  constricting  wire  shall  at  all  points  lie  upon 
peritoneal  membrane.  In  some  cases  it  would  be  quite  easy  to 
apply  the  wire  around  the  fibrous  or  tumour  tissue  alone,  at  the 
pedicle,  without  including  the  peritoneal  investment  at  all ;  the 
peritoneum  might  then  be  used  as  a  funnel  to  shut  off  the 
sloughing"  pedicle  from  the  cavity,  simply  by  fixing  it  to  the 
parietal  wound  with  a  few  stitches.  But  adhesions  form  so 
rapidly  between  parietal  peritoneum  and  that  covering  the 
pedicle,  that  the  cavity  is  usually  completely  shut  off  before 
sloughing  has  set  in. 

The  part  of  the  pedicle  beyond  the  wire  or  the  ligature  is 
removed  by  pressure  necrosis.  A  sort  of  dry  gangrene  which 
is  not  actively  putrefactive,  and  which  does  not  set  loose  foul 
discharges,  is  sought  to  be  produced  by  various  means.  Soaking 
with  strong  perchloride  of  iron,  or  with  tannin  or  alum,  is  used 
for  this  purpose.  Bantock  has  found  that  the  simple  applica- 
tion of  dry  absorbent  wool  mummifies  the  tissues,  and  renders 
them  almost  as  hard  as  wood  :  and  I  have  been  able  in  my 
own  practice  to  confirm  his  experience.  The  process  of  sepa- 
ration is  accelerated  by  a  few  turns  of  the  screw  every  second 
or  third  day,  and  complete  separation  usually  takes  place  in 
from  seven  to  fourteen  days.  Little  pieces  of  dry  absorbent  lint 
are  packed  round  the  pedicle  to  absorb  all  discharge  as  it 
appears,  and  to  prevent  its  burrowing  along  the  line  of  incision 
or  trickling  into  the  abdomen.  These  are  changed  as  often  as 
necessary.  The  abdominal  wound,  if  properly  shut  off,  need  not 
be  looked  at  for  a  week,  when  it  will  probably  be  found  healed. 

When  the  pedicle  separates,  a  deep  granulating  hollow  is  left, 
which  usually  fills  up  and  skins  over  at  the  end  of  two  or  three 
weeks.  In  a  few  cases  the  granulations  are  not  perfectly  covered 
with  cuticle  for  months ;  and  in  such  cases  an  occasional  discharge 
of  blood,  coincidently  with  the  menstrual  periods,  is  observed. 


266  HYSTERECTOMY  FOR  MYOMA. 

The  combined  intra-  and  extra-peritoneal  method  of  treating 
the  pedicle  is  usually  one  of  necessity,  and  not  of  choice. 
It  is  used  in  cases  where  the  pedicle  cannot  be  pulled  out- 
side the  parietes  without  exerting  dangerous  tension  on  the 
parts. 

The  simplest  method  of  "  mixed  "  treatment  of  the  pedicle  is 
where  it  is  secured  by  ligatures,  and  the  ends  of  these  ligatures 
are  fixed  in  the  inferior  angle  of  the  wound.  The  same  treat- 
ment may  be  carried  out  where  serre-noeud  or  elastic  ligature  is 
used.  The  margins  of  the  pedicle  are  stitched  to  the  parietal 
wound,  and  the  pedicle,  with  its  constricting  apparatus,  is 
dragged  some  little  way  inside  the  abdomen.  Additional 
security  against  the  escape  of  discharges  into  the  cavity  is  got 
by  stitching  the  parietal  peritoneum  to  the  side  of  the  pedicle 
below  the  point  of  constriction.  Various  devices*  have  been 
invented  to  shut  off  the  pedicle  from  the  general  cavity.  One 
of  these  is,  to  surround  it  with  macintosh  sheeting  or  gutta- 
percha tissue,  as  in  a  funnel. 

The  mixed  treatment,  at  its  best,  is  suspension  and  inter- 
parietal fixation.  Perfect  drainage,  frequent  removal  of  dis- 
charges, and  absolute  rest  may  make  it  practically  extra- 
peritoneal. 

According  to  Vautrin,  in  supra-vaginal  amputations  the 
general  mortality,  with  intra-peritoneal  treatment  of  the  pedicle, 
is  56.2  per  cent.;  with  extra-peritoneal,  33.3  per  cent.  Although 
this  death-rate  is  far  in  excess  of  what  may  be  termed  the 
legitimate  mortality — that  is  to  say,  the  mortality  in  the  hands 
of  the  best  operators, — it  is  more  than  probable  that  the 
proportionate  mortality  is  the  same  all  round.  In  other 
words,  the  dangers  of  the  intra-peritoneal  treatment  are 
nearly  twice  as  great  as  the  extra-peritoneal.  At  present, 
therefore,  the  extra-peritoneal  treatment  of  the  pedicle  should 
be  selected.  No  doubt  the  advancing  surgery  of  the  day  will 
not  rest    till  some    intra-peritoneal  method   has  been    devised 

*  A  very  full  account  of  these  may  be  found  in  Vautrin's  book,  already 

referred  to. 


AFTER-TREATMENT.  267 

which  will  excel  all  others :  in  the  meantime,  our  present 
knowledge  and  experience  are  in  favour  of  the  extra-peritoneal 
method. 

After-treatment. — The  general  after-treatment  requires  no 
special  description,  being,  to  all  intents  and  purposes,  the 
same  as  after  ovariotomy.  There  is  usually  more  pain  ;  and 
the  bladder,  having  less  room  to  expand,  requires  to  be  emptied 
more  frequently  than  in  ovariotomy.  Pain  is  often  relieved  by 
emptying  the  bladder. 

The  nurse  must  look  sharply  after  the  stump,  to  see  that 
haemorrhage  does  not  take  place  ;  and  she  must  be  carefully 
instructed  how  to  tighten  the  screw  and  check  it.  The  tighter 
the  wire  is  kept  (short  of  cutting),  the  sooner  the  stump 
dries  up. 

When  the  pedicle  is  converted  into  a  hard  dry  mass  the 
serre-noeud  may  be  removed,  but  the  needles  should  not  be 
disturbed.  I  now  usually  remove  the  clamp  on  the  third  or 
fourth  day,  and  do  not  tighten  it  up  after  operation.  The 
pedicle  usually  sloughs  for  some  distance  behind  the  wire  as 
well  as  in  front  of  it ;  and  if  the  needles  are  removed  before 
the  slough  separates,  the  whole  is  retracted  inside  the  cavity 
and  gives  some  trouble  in  its  removal.  If  the  needles  are 
removed  at  all,  it  should  be  in  order  that  they  may  be  re- 
inserted lower  down  in  the  substance  of  the  slough  ;  then  all 
the  tissue  above  them  should  be  cut  away,  except  sufficient  to 
hold  by.  Stimulating  lotions  promote  the  formation  of  granu- 
lations, and  thereby  accelerate  the  separation  of  the  slough. 
Dry  strips  of  boracic  lint  or  other  absorbent  dressing  should  be 
laid  around  the  slough,  and  changed  frequently,  so  as  to  keep 
the  pus  from  burrowing  downwards. 


Section  V. 


OPERATIONS  ON   THE  GRAVID   UTERUS, 
AND   FOR   ECTOPIC   GESTATION. 


To  save  life  in  cases  where,  from  any  cause,  delivery  cannot 
take  place  through  the  natural  passages,  at  least  five  distinct 
operations  have  been  recommended,  besides  a  number  of  modi- 
fications of  these.  They  are  :  Caesarean  section  ;  Utero-ovarian 
amputation,  or  Porro's  operation  ;  Laparo-elytrotomy ;  Total 
extirpation  of  the  uterus  ;  and  Symphysiotomy. 

Two  of  these,  the  last,  may  be  at  once  dismissed.  Sym- 
physiotomy, or  section  of  the  pubic  symphysis  for  increasing 
the  space  of  the  pelvic  cavity,  was  proposed  in  1768  by  Sigault^ 
and  successfully  carried  out  by  him  nine  years  later.  The 
operation  has  not,  however,  come  into  general  use,  most  men 
believing  that,  in  those  cases  where  it  is  likely  to  be  successful, 
other  and  less  dangerous  modes  of  delivery  are  possible. 


OPERATIONS   ON   THE   GRAVID    UTERUS.  269 

The  allied  operations  of  Pelviotomy  (Galbiati)  and  Pubi- 
otomy  (Stoltz)  have  also  failed  to  secure  the  confidence  of  the 
profession. 

Total  extirpation  of  the  pregnant  uterus  has  been  performed 
only  during  the  co-existence  of  cancer,  and  then  the  operation 
has  been  rather  the  extirpation  of  a  cancerous  organ  which 
happened  to  contain  a  foetus,  than  one  designed  to  save  life 
endangered  by  obstruction  to  delivery.  Bischoff*  operated,  in 
1879,  on  a  patient  with  cancer  of  the  cervix  in  the  thirty-fourth 
week  of  pregnancy.  The  patient  died  in  eleven  hours  ;  and  at 
the  necropsy  one  ureter  was  found  enclosed  in  the  ligature.  In 
1 881  Spencer  Wells  removed  by  abdominal  section  a  cancerous 
uterus  six  months  pregnant.  The  patient  recovered  from  the 
operation ;  but  the  disease  recurred  not  long  afterwards. 
A  case  in  w^hich  the  writer  removed  a  cancerous  and 
pregnant  uterus  by  the  vagina  during  the  second  month 
of  gestation  can  scarcely  be  included  in  this  category. 
The  patient  recovered,  and  as  yet,  after  a  year  and  a  half, 
continues  well. 

Full  consideration  is  given  to  three  operations  : 

Caesarean  Section. 
Porro's  Operation. 
Laparo-elytrotomy. 

And,  further,  it  will  be  necessary  to  describe  separately  the 
surgical  treatment  of 

Rupture  of  the  Uterus. 

Extra-uterine  Pregnancy. 

Pregnancy  in  one  horn  of  a  Uterus  bicornis. 

With  reference  to  Caesarean  section,  Porro's  operation,  and 
Laparo-elytrotomy,  the  mortality,  indications  to  operate,  and 
appreciation,  will  be  considered  conjointly  and,  as  far  as 
possible,  comparatively ;  so  that,  if  such  a  practice  be  pos- 
sible, there  may  be  a  selection  of  method  according  to  the 
nature  of  the  case. 

•  Hegar  und  Kaltenbach.      Openit.  Gyndh.,  2nd  Ed.,  Stuttgart,  1S81,  p.  414. 


270  OPERATIONS  ON   THE   GRAVID    UTERUS. 


SURGICAL    ANATOMY    OF    THE    GRAVID    UTERUS. 

The  elaborate  studies  of  Polk*  on  the  relational  anatomy 
of  the  gravid  uterus  are  of  great  value.  I  have  been  able 
to  supplement  and  confirm  Polk's  observations  by  two  dis- 
sections,  specially  made  in  view  of  surgical  procedures.  One 
was  obtained  from  a  patient  in  the  ninth  month  of  pregnancy, 
who  died  of  acute  chorea.  The  other,  in  which  labour  had 
advanced  till  the  os  uteri  was  dilated  to  the  size  of  a  crown- 
piece,  was  got  from  a  patient  who  died  from  fracture  of  the 
spine,  caused  by  a  fall.  Both  dissections  are  now  in  the 
museum  of  the  Bristol  Infirmary. 

During  pregnancy  changes  take  place  in  the  relations  of  the 
peritoneum,  the  uterine  and  ovarian  arteries,  the  uterine  liga- 
ments, and  the  ureters. 

As  the  uterus  rises  out  of  the  pelvis,  it  carries  the  peritoneum 
with  it.  The  elevation  of  the  pelvic  peritoneum,  near  the  end 
of  pregnancy,  is  so  great  that  the  reflection  from  the  parietes  to 
the  uterus  takes  place  somewhere  near  the  level  of  Poupart's 
ligament.  At  the  same  time  the  cellular  tissue  becomes  lax 
and  distensile,  and  the  attachment  of  the  peritoneum  is  much 
loosened.  This  elevation  of  peritoneum  and  laxity  of  cellular 
tissue  is  so  marked,  that  if  an  abdominal  section  is  made  trans- 
versely at  the  level  of  the  internal  ring,  and  the  uterus  is  pushed 
to  the  opposite  side,  the  true  pelvis  may  be  entered  without 
encountering  peritoneum  at  all.  Even  if  it  bulges  into  the 
incision,  it  can  easily  be  pushed  upwards.  This  change  in  the 
relation  of  the  peritoneum  renders  the  operation  of  Laparo- 
elytrotomy  possible. 

The  broad  ligaments  are  lifted  out  of  the  pelvis  altogether, 
and  become  triangular  instead  of  being  quadrangular.  The 
inner  border,  descending  from  the  cornu  to  the  internal  os,  is 
much  broadened  :  its  layers  are  separated  and  loosely  attached, 
especially  the  anterior  layer  passing  over  the  front  of  the  uterus. 
The  superior  border,  running  between  cornu  and  pelvic  brim,  is 

New  York  Med.  Journ.,  1884. 


SURGICAL   ANATOMY. 


271 


almost  perpendicular.  The  lower  border,  partaking  of  the 
general  elevation  of  the  pelvic  brim,  now  occupies  the  level  of 
the  upper  border  in  the  non-pregnant  state,  running  straight 
across  from  pelvic  brim  to  uterus.  The  outer  border  is  obliter- 
ated. The  uterus  may,  in  fact,  be  considered  as  growing 
upwards  between  the  folds  of  the  broad  ligaments,  carrying 

these    and   the   peritoneum 
continuous  with  it. 

The  round  ligaments, 
greatly  enlarged  and  elon- 
gated, descend  in  the  ante- 
rior folds  of  the  broad 
ligaments  in  straight  lines 
from  their  insertion  at  the 
cornua  to  the  internal 
rings.  Nowhere  do  they 
descend  below  the  pelvic 
brim.  They  may  be  con- 
sidered as  instrumental  in 
raising  the  peritoneum  from 
the  iliac  fossae. 

The  arteries  are  much 
enlarged — the  ovarian 
more,  in  proportion,  than 
the  uterine.  The  uterine 
artery  is  straightened,  and 
is  elevated  so  that  it  is,  in 
part,  removed  from  the 
pelvic  wall.  Its  relations 
to  the  ureter  are  not  much 
changed.  The  ovarian  ar- 
tery, after  it  reaches  the 
bifurcation  of  the  iliac,  runs  upwards  and  forwards  to  the 
elevated  cornu  in  the  posterior  border  of  the  expanded  upper 
portion  of  the  broad  ligament. 

The  relations  of  the  ureters  are,  in  one  of  these  operations, 
exceedingly  important.     They  are,  at  full  term,  detached  from 


Fig.  45. 

Outline  draiving  from  dried  preparation  oj 

uterus  near  termination  of  first  stage 
of  labour.     (Bristol    Infirmary   Museum.) 

ut.,  uterus;  v.,  vagina;  bl.,  bladder;  r., 
rectum;  d.p.,  Douglas'  pouch;  tir.,  ureter; 
dotted  line  at  level  of  external  os  ;  x,  at  line  of 
incision  through  vagina  in  Laparo-Elytrotomy. 
Shading  is  placed  on  the  areas  closely  invested 
by  peritoneum. 


272  OPERATIONS   ON   THE   GRAVID    UTERUS. 

the  pelvic  wall  and  elevated  along  with  the  vagina  and  bladder. 
They  lie  very  closely  to  the  vagina  on  its  antero-lateral  aspects, 
and  strike  the  bladder  about  three-quarters  of  an  inch  below 
the  cervico-vaginal  junction.  These  relations  are  not  much 
changed  during  labour.  As  the  head  descends  and  fills  the 
parturient  canal,  the  ureters  are  pushed  apart.  They  now  lie 
in  close  contact  with  the  vaginal  and  uterine  walls,  amongst 
the  plexus  of  vessels.  The  relation  of  ureter  to  external  os 
at  the  end  of  the  first  stage  of  labour — that  is  to  say,  at  the 
most  important  surgical  period — is  shown  in  the  accompanying 
diagram,  made  from  a  special  dissection.  (Fig.  45.)  In  a  full 
lateral  view,  the  ureter  crosses  the  line  of  the  os  uteri  obliquely 
near  the  junction  of  its  anterior  with  its  middle  third.  In  other 
words,  at  the  level  of  the  external  os  the  space  between  ureter 
and  rectum  is  twice  as  great  as  that  between  ureter  and  bladder. 
The  importance  of  these  relations  in  laparo-elytrotomy  will  be 
seen  presently.  The  ureter  leaves  the  uterus  behind  out  of  the 
range  of  danger  in  Porro's  operation,  unless  the  pedicle  is 
constricted  very  low  down. 


Csesarean  Section.    Puerperal  Hysterotomy. 

History. — The  removal  of  a  child  from  a  mother  who  fails  to 
deliver  it  is  a  very  old  operation.  At  first  performed  only  when 
the  mother  was  dead,  the  operation  afterwards  came  into  use 
while  she  was  still  alive.  Whether  or  not  we  accept  the  inter- 
pretation given  to  the  sentence  in  Pliny  ("  Auspicatius,  enecata 
parente,  gignuntur  sicut  Scipio  Africanus  prior  natus,  primusque 
Caesarum  a  caeso  matris  utero  dictus"),  there  is  no  doubt  that 
the  name  Caesarean  was  very  earl}^  given  to  the  operation  ; 
and  many  historical  personages  —  among  others,  Manilius, 
Edward  VI.  of  England,  and  Sanctus,  King  of  Navarre — have 
been  called  Caesars  from  their  having  been  supposed  to  be  cut 
out  of  their  mother's  womb.  According  to  Heister,*  the  Greeks 
were  acquainted  with  the  operation  of  removing  the  child 
while  the  mother  was  alive,  and  named  it  "  Hysterotomia." 
There  is  little  doubt  that  it  was  practised  among  the  Jews  from 
very  ancient  times.  In  later  times,  the  operation  was  done 
here  and  there  ;  but  full  and  authentic  records  of  it  are  wanting. 
The  first  case  recorded  with  anything  like  circumstantial  minute- 
ness is  that  done  in  1500  by  the  Chatreur  or  sow-gelder  of 
Seigerheusen,  who  operated  on  his  own  wife,  as  recorded  by 
Caspar  Bauhin  in  his  appendix  to  Roussetus's  great  work. 
The  woman  had  been  in  labour  for  some  days,  and  had  been 
attended  by  thirteen  midwives  and  several  lithotomists.  These 
the  sow-gelder  sent  about  their  business,  and  he  extracted  the 
infant  with  success  to  both  mother  and  child.  W.  Simmons, 
surgeon  to  the  Manchester  Infirmary,  who  published  a  very 
able  monograph  on  the  subject  in  1799,  believes  that  this  case 
was  really  one  of  extra-uterine  foetation.  Whether  this  was  so 
we  cannot  now  decide ;  but  the  influence  of  this  obscure  oper- 
ator was  not  felt  till  after  the  pubHcation,  in  1581,  of  the  first 
elaborate  work  on  the  operation  by  Roussetus.f     By  a  careful 

*  System  of  Siirgeiy,  1750,  vol.  ii.,  p.  27. 

t  Traiie  nouveau  de  I'Hysterotomotokie  ou  enfantcment  Cdsaykn,  qui  est  extvaition 

de  V  enfant  par  incision  laterale  du  ventre  et  matrice  de  la  femvie,  &c. 

19 


274  CESAREAN  SECTION. 

record  of  seven  cases,  and  an  elaborate  discussion  of  all  the 
details  of  the  operation,  he  sought  to  place  it  upon  a  scientific 
basis.  Bauhin,  in  1582,  translated  this  work  into  Latin,  and 
added  an  appendix.  Guillemeau,  Marchant  (both  Paris  sur- 
geons), and  others,  having  utterly  failed  in  the  practice  of  the 
operation,  unhesitatingly  condemned  it ;  to  these  Roussetus,  in 
1590,  replied,*  placing  the  operation  on  a  more  secure  basis. 
In  1604  Scipio  Mercurius,  a  Roman  surgeon,  in  his  work  on 
Midwifery,  published  in  Venice,  advises  hysterotomy  in  suitable 
cases.  Soon  after  this,  Schenkius  ;  Roonhuisen,  an  Amsterdam 
surgeon;  Sonnius,  a  physician  of  Bruges;  Rudbeckius,  a  Swede  ; 
Bartholini ;  Renaud ;  Saviare,  and  others  practised  and  wrote 
upon  the  operation.  In  1695  Valerusf  published  a  treatise  on 
the  operation.  Ruleau,  a  surgeon  of  Xaintes,  seems  to  have 
had  a  successful  case  about  the  beginning  of  the  eighteenth 
century;  and  Dionis]: — who,  however,  is  strongly  against  the 
proceeding — by  investigations  made  subsequently  on  the  spot, 
satisfied  himself  as  to  the  authenticity  of  this  operation. 
Sennertus,  Hildanus,  and  Scultetus,  may  be  quoted  as 
favouring  the  operation  ;  Pare,  however,  was  distinctly 
against  it. 

A  notable  contribution  both  to  the  history  and  the  science 
of  the  subject  was  made  by  M.  Simon  in  the  first  volume  of 
the  Memoirs  of  the  Royal  Academy  of  Surgery,  in  which  also 
various  cases  are  recorded,  with  not  very  encouraging  success. 
A  similar  want  of  success  seems  to  have  followed  operation 
everywhere.  In  Vienna,  Godson  tells  us,  the  operation  was 
done  for  a  hundred  years  without  a  single  success ;  and  in  the 
Maternite,  at  Paris,  a  similar  story  was  told.  Chiara  of  Milan 
gathered  62  operations,  with  only  three  recoveries.  In  England 
an  almost  equally  dismal  record  is  given  for  the  eighteenth  and 
even  part  of  the  nineteenth  centuries.  Here  and  there  a  success 
is  recorded — not  always,  however,  by  leaders  in  surgery,  who, 
as  a  rule,  were  opposed  to  it.     One  such  case  is  recorded  by 

*  In  Dialogus  pro  Casareo  partu,  &c.,  Paris,  1590. 

t  Dissert,  de  partu  Cc^sareo,  Viteberga,  1695. 

J  A  Course  of  Chiriirgical  Operations,  Eng.  Trans.,  Lond.,  1733. 


THE  OPERATION.  275 

Mr.  Duncan  Stewart,*  in  which  a  midwife — who  seems,  how- 
ever, to  have  been  a  consultant  among  her  class — operated 
successfully  with  a  razor.  Unlike  most  operators,  she  made 
her  incision  in  the  middle  line ;  she  closed  the  wound  with 
tailors'  needles  and  silk,  used  like  hare-lip  pins.  The  patient 
was  seen  afterwards  quite  well,  but  with  a  ventral  hernia. 

A  good  many  examples  of  Csesarean  section  performed  by 
the  patient  herself  are  on  record.  Among  the  most  remarkable 
of  these  is  that  recorded  by  von  Guggenberg,f  where  the  woman 
succeeded  in  removing  the  child ;  and  all  that  was  left  for  the 
surgeon  to  do  was  to  close  the  openings.  Another^ — in  which 
the  patient,  two  hours  after  operating  on  herself,  walked  a  kilo- 
metre, breakfasted  with  a  sister,  and  then  walked  about  for  some 
time,  had  protrusion  of  intestines,  and  (with  medical  assistance) 
recovered — is  even  more  remarkable. 

The  impetus  recently  given  to  abdominal  surgery  has  spread 
to  all  operations  for  removing  the  foetus,  and  not  least  power- 
fully to  Caesarean  section.  And,  particularly  within  the  last  few 
years,  the  comparative  want  of  success  of  Porro's  operation  in 
Germany  and  elsewhere  has  led  to  the  devotion  of  increased 
attention  to  certain  details  in  ordinary  hysterotomy  which  place 
it  in  a  position  of  rivalry  with,  if  not  of  superiority  to,  hyster- 
ectomy. 

THE    OPERATION    OF    CESAREAN    SECTION. 

When  it  has  been  decided,  in  any  given  case,  that  puerperal 
hysterotomy  is  to  be  performed,  the  sooner  it  is  carried  out  the 
better.  The  condition  of  the  patient,  already  in  all  probability 
not  very  favourable,  rapidly  deteriorates ;  and  the  local  etTects 
of  prolonged  contraction  of  the  uterine  fibre,  exhausting  its 
vitality,  are  not  conducive  to  subsequent  healing.  Therefore, 
though  it  is  advisable  to  operate  with  a  cleansed  vagina,  no 
time  which  delays  operation  is  to  be  spent  in  doing  this. 
Cleansing  may  be  carried  out  after  operation  is  over.  The 
abdomen  may  be  rapidly  purified  with   carbolic  or  corrosive 

*  Med.  Essays  and  Observations,  Edin. ,  vol.  v.,  p.  361,  1752. 

t  Lancet,  1886,  i.,  p  90  {  Lancet,  May  22nc],  1S86. 

19  * 


276  CESAREAN  SECTION. 

sublimate  lotion,  and  particular  attention  must  be  paid  to  the 
umbilicus.  Shaving  adds  to  the  security.  The  general  arrange- 
ments for  operation  are  the  same  as  those  already  described  for 
abdominal  operations  in  general. 

I  should  always  use  antiseptics  in  their  fullest  details.  The 
instruments  required  are  very  few  and  simple.  A  scalpel,  a 
pair  of  scissors,  and  a  dozen  pairs  of  locking  forceps,  with  the 
necessary  complement  of  needles,  sutures,  ligatures,  and  sponges, 
are  all  that  are  wanted.  Two  long  flat  sponges  will  be  found 
very  useful.  In  every  case  we  ought  to  be  provided  with  a 
clamp  and  other  instruments  necessary  for  a  possible  hyster- 
ectomy. 

The  Parietal  Incision. — The  abdominal  opening,  which  used  to 
be  made  to  one  side  of  the  median  line,  is  now  always  made 
along  it,  and  in  the  same  manner  as  for  ovariotomy.  But  the 
primary  incision  is  longer,  and  does  not  descend  so  low,  while  it 
rises  higher.  The  elevation  of  the  bladder  renders  it  inadvisable 
to  approach  within  a  distance  of  two  or  two  and  a  half  inches 
from  the  pubes.  Above  this  point  an  incision  of  five  inches  may 
be  made.  According  to  the  size  of  the  patient,  the  upper  limit 
will  reach  to,  or  pass  a  varying  distance  beyond,  the  umbilicus. 
According  to  Sanger,  a  suitable  incision  will  in  most  cases  be 
one-third  of  its  length  above  the  umbilicus,  and  two-thirds  below 
it.  The  cut  may  go  straight  through  the  umbilicus  ;  but,  for 
reasons  given  elsewhere,  I  think  it  is  better  that  it  should  pass 
to  the  left  of  it.  If,  as  some  surgeons  recommend,  the  uterus 
is  to  be  turned  out  of  the  wound  before  opening  it,  then  the 
incision  must  be  made  considerably  longer.  More  will  be  said 
on  this  proceeding.  The  intention,  in  the  operation  to  be 
described,  is  to  give  sufficient  space — firstl}',  for  removal  of  the 
child ;  and  secondly,  for  suturing  the  wound  in  the  uterus. 

Opening  the  Uterus,  Extraction  af  Foetus. — In  making  the  wound 
in  the  uterine  walls,  we  have  to  bear  in  mind  avoidance  of 
haemorrhage  and  the  encouragement  of  subsequent  union.  If 
the  incision  is  carried  too  low,  the  branches  of  the  uterine  artery 


THE   UTERINE  INCISION.  277 

are  endangered.  The  anterior  reflection  of  the  peritoneum  from 
the  uterus  is  a  good  guide.  Here  the  peritoneum  is  loosely 
attached  and  somewhat  freely  movable.  The  lower  limit  of  the 
incision  may  enter  this  region.  So  far  as  bleeding  is  concerned, 
the  upper  limits  of  the  incision  are  unimportant.  The  position 
of  the  placenta  might  be  supposed  to  have  an  important  influ- 
ence on  the  selection  of  the  line  for  the  uterine  wound,  but, 
practically,  this  would  seem  not  to  be  so.  Still,  if  it  is  possible 
to  make  out  the  site  of  the  attachment  of  the  placenta  before 
incising  the  uterus  (always  difficult,  often  impossible  according 
to  most  writers),  the  operation  might  be  rendered  easier  by 
avoiding  this  area.  No  extraordinary  trouble  need  be  taken  to 
avoid  it,  however.     A  vertical  incision  is  recommended. 

The  line  of  incision  being  fixed  upon,  two  long  flat  sponges 
are  placed,  one  on  each  side  of  it,  between  the  uterus  and  the 
parietes.  An  assistant,  standing  on  the  left  side  of  the  patient, 
opposite  to  the  surgeon,  places  a  hand  deepl}'  in  each  flank 
behind  the  uterus,  and  makes  the  uterus  bulge  forward  into  the 
parietal  opening,  firmly  holding  it  there.  By  this  manoeuvre, 
and  with  the  intervention  of  the  flat  sponges,  the  risks  of 
escape  of  fluids  into  the  abdomen  are  minimised.  The  uterus 
is  so  placed  and  fixed  that  the  incision  through  its  walls  will 
correspond  to  the  parietal  incision. 

As  to  the  best  mode  of  making  the  uterine  incision,  many 
opinions  are  held.  Some  recommend  tearing ;  others,  a  com- 
bination of  cutting  and  tearing ;  others,  pure  cutting.  Some 
recommend  a  dissection  deliberately  carried  out,  each  vessel 
being  caught  in  forceps  as  it  bleeds.  To  prevent  bleeding,  the 
placing  of  a  temporary  ligature  around  the  neck  of  the  uterus 
has  been  used  by  several  surgeons  ;  by  others,  equally  trust- 
worthy, it  has  been  neglected.  As  a  matter  of  fact,  the  bleeding 
is  rarely  severe ;  but  should  it  chance  to  be  alarming,  a  sponge 
may  be  packed  into  the  wound  to  check  it  while  the  elastic 
ligature  is  slipped  over  the  uterus  to  its  neck  and  tightened.  In 
the  absence  of  a  proper  tourniquet,  a  simple  knot  may  be  cast 
and  tightened  ;  while  it  can  easily  be  prevented  from  becoming 
undone  by  placing  a  catch  forceps  upon  it.     In  every  case  it  is 


278  CESAREAN  SECTION. 

best  to  do  without  the  use  of  a  constricting  hgature,  if  that  is 
possible  ;  every  increase  of  traumatism  adds  to  the  danger. 

I  am  in  favour  of  a  clean-cut  incision.  At  the  upper  end  of 
the  projected  incision,  where  the  uterus  is  least  vascular,  an 
opening  an  inch  in  length  is  rapidly  made  by  the  scalpel.  The 
opening  need  not  completely  perforate  the  uterine  walls,  but 
may  be  completed  by  pushing  the  finger  through  it.  If  the 
membranes  are  intact,  a  condition  which  is  considered  favourable, 
they  need  not  now  be  divided ;  but  it  can  matter  little  if  they 
are  divided  by  the  finger.  The  incision  is  now  rapidly  completed 
downwards,  by  scissors  cutting  on  the  finger  as  a  director.  A 
few  seconds  suffice  for  this  part  of  the  proceeding.  The  scissors 
is  now  thrown  aside,  and  the  hand  plunged  through  the  opening 
catches  the  head  of  the  child,  the  fingers  clipping  the  neck.  If 
the  feet  are  conveniently  near,  the  child  may  be  extracted  by 
grasping  them  ;  but  as  the  uterine  opening  may  contract  round 
the  following  neck,  it  is  better  to  extract  by  the  head.  If, 
during  extraction  by  the  feet,  the  head  is  caught  in  the  uterine 
opening,  the  incision  should  be  prolonged  upwards  to  prevent 
downward  laceration  of  the  uterine  walls. 

Uterine  action  will  have  been  going  on  all  this  time,  and 
gushes  of  amniotic  fluid  will  have  escaped  from  the  uterus  and 
run  over  the  macintosh  plastered  round  the  abdominal  opening. 
The  assistant,  meanwhile,  will  have  carefully  kept  the  uterus 
pressed  forward  on  to  the  abdominal  walls :  if  he  is  skilled  and 
attentive,  no  fluids  will  enter  the  abdomen. 

The  umbilical  cord  is  now  divided  between  two  pairs  of 
locking  forceps,  and  the  child  is  handed  over  to  an  assistant. 
The  surgeon  then  directs  his  attention  to  the  detachment  of  the 
placenta,  and  the  bleeding  in  the  uterine  wound. 

If  the  uterus  is  contracting  well,  bleeding  from  the  uterine 
sinuses  soon  ceases,  and  the  placenta  becomes  spontaneously 
detached.  At  least  one  surgeon  seems  to  have  been  able  to 
increase  the  vigour  of  uterine  contraction  by  the  application  of 
electricity,  and  this  hint  is  well  worthy  of  attention.  A  hypo- 
dermic injection  of  ergotine  is  advisable  at  this  stage.  If  the 
condition  of  the  patient  permits  of  it,  it  is  always  best  to  wait 


CLOSURE  OF  THE    UTERINE    WOUND.  279 

for  spontaneous  detachment  of  the  placenta.  During  this 
period  it  is  easy  enough  to  control  bleeding  from  the  uterine 
sinuses  b}^  compression  b}^  sponges,  or,  if  necessary,  by  forceps. 
If,  after  a  timely  delay,  the  placenta  is  not  detached,  we  may 
encourage  detachment  with  the  fingers ;  but  if  the  uterus  still 
refuses  to  contract,  and  if  bleeding  continues  free  from  the 
uterine  incision,  then  we  ought  to  proceed  to  hysterectomy  by 
Porro's  method.  The  secret  of  success  in  simple  hysterotomy 
is  efficient  contraction  of  the  uterus ;  if  this  fails  us,  the  next 
best  proceeding  is  hysterectomy. 

In  the  great  majority  of  cases,  operated  upon  sufficiently 
early,  the  uterus  contracts,  the  placenta  is  spontaneously 
detached,  and  the  haemorrhage  from  the  uterine  sinuses  spon- 
taneously ceases,  or  becomes  unimportant.  Careful  attention  is 
bestowed  on  the  complete  and  thorough  removal  of  the  secun- 
dines.  When  the  uterus  is  empty,  it  may  be  advisable  to  push 
a  drainage  tube  or  probang  through  the  cervix  and  vagina,  and 
leave  it  there  to  act  as  a  drain.  In  any  case,  permeability 
towards  the  vagina  will  have  been  ascertained  before  closure  of 
the  uterine  wound  is  begun.  There  is  little  use  in  mopping  out 
the  uterine  cavity  ;  it  soon  refills.  Generally  speaking,  the  less 
manipulation  the  better :  the  process  of  parturition  physio- 
logically looks  after  itself;  meddlesome  interference  means,  in 
many  cases,  harmful  traumatism. 

If  the  uterus  has  contracted  well,  and  seems  to  be  small 
enough  easily  to  be  pushed  by  the  assistant  through  the 
parietal  opening,  there  is  no  strong  objection  to  this  being  done. 
It  prevents  the  escape  of  blood  into  the  cavity  during  the 
extraction  of  the  placenta,  and  facilitates  the  insertion  of 
sutures.  Most  surgeons  would,  however,  dread  the  risks  from 
additional  traumatism  thus  induced. 

Closure  of  the  Uterine  Wound. — There  is  a  very  general  con- 
sensus of  opinion  that  on  this  detail,  more  than  on  any  other, 
depends  the  success  of  Caesarean  section.  No  doubt  this  is  so. 
But  many  cases  of  recovery  are  on  record  in  which  no  closure 
has  been  attempted ;  the  wound  has  been  left  to  close  by  uterine 


280  CESAREAN  SECTION. 

contraction.  On  the  other  hand,  it  would  seem  that  if  uterine 
contraction  fails,  mere  suturing  is  not  always  sufficient.  Accu- 
rate suturing",  plus  uterine  contraction,  give  the  best  results. 

The  problem  is  complicated.  The  natural  involution  of  the 
uterus  induces  an  atrophy  of  uterine  fibres,  which  is  degener- 
ative and  attended  with  the  free  discharge  of  fluids.  This 
process  is,  in  wounds  of  uterine  tissue  proper,  strongly  preju- 
dicial to  union  by  adhesive  inflammation.  Uterine  contractions 
going  on  after  delivery,  mean  that  a  condition  of  unrest  exists 
in  the  uterine  wound.  This  is  another  bar  to  union.  And  this 
unrest  and  the  delayed  union  permit  of  the  escape  of  intra- 
uterine fluids  through  the  wound  into  the  peritoneum — a  con- 
tingency which  is  full  of  danger. 

The  methods  of  suturing  the  uterine  wound  are  very  nu- 
merous. Lebas,  in  1769,  first  introduced  sutures.  Polin  of 
Kentucky  in  1852  first  introduced  the  silver  suture ;  and  this 
has  always  been  a  favourite  material.  Hemp,  catgut,  silk,  and 
other  materials,  have  been  used  ;  and  the  sutures  have  been 
placed  in  a  great  number  of  ways — deep,  superficial,  continuous, 
interrupted,  singly,  and  in  combinations.  Wells,  in  a  successful 
case,  used  a  continuous  silk  suture,  one  end  of  which  he  carried 
through  the  vagina,  subsequently  removing  it  by  traction. 
But  the  success  after  any  method  was  not  encouraging. 

Within  the  past  few  years  special  attention  has  been  devoted 
by  several  German  surgeons  to  the  mode  of  suturing  the  uterine 
wound,  and  with  a  success  which  is  remarkable  and  striking. 
The  extraordinary  capacity  of  serous  surfaces  to  become  quickly 
glued  together  by  inflammatory  adhesions  had  been  fully  proved 
in  abdominal  surgery.  In  gastrostomy,  enterotomy,  and  enter- 
ectomy,  it  had  been  shown  that  apposition  of  serous  surfaces, 
with  fixation  by  suitable  and  numerous  sutures,  was  followed 
by  agglutination  so  intimate  and  strong  that  escape  of  fluids  or 
gases  was  impossible.  The  danger  in  Caesarean  section  arose 
from  gaping  of  the  uterine  wound,  which  took  place  from  the 
natural  shrinkage  of  the  uterine  fibre.  As  the  fibres  shrank  the 
sutures  became  loose ;  and  they  might  even  act  as  setons, 
encouraging  the  escape  of  uterine  secretions.     The  principle  of 


CLOSURE  OF  THE    UTERINE    WOUND.  281 

the  new  improvement  was,  to  look  to  the  peritoneum  for  the 
perfect  closure  of  the  uterine  wound  towards  the  abdomen. 

Though  Van  Aubel  is  said  to  have  suggested  this  method  in 
1862,  Sanger,  who  published  his  ideas  in  1882,*  deserves  the 
chief  merit  of  having  introduced  it.  Leopold  was  the  first 
actually  to  carry  it  out.  Beumer,  Obermann,  Miinster,  Crede, 
and  others  soon  followed;  and  the  combined  results  of  thest 
operators,  in  the  short  time  during  which  they  have  been 
working,  have  already  placed  the  improved  mode  of  Caesarean 
section  by  the  conservative  Sanger  or  Sanger-Leopold  method 
ahead  of  all  others. 

Many  variations  in  detail  have  been  given.  Sanger  at 
first  recommended  resection  of  a  wedge-shaped  strip  of  mus- 
cular fibre  under  the  peritoneal  covering,  so  as  to  permit  of  the 
infolding  of  a  greater  amount  of  serous  surface.  This  was 
found  to  be  unnecessary,  and  sometimes  even  harmful.  It  is 
usually  possible,  without  resection  of  muscular  tissue,  to  fold 
inwards  sufficient  breadth  of  serous  surface.  It  is  unnecessary 
to  recapitulate  every  variety  of  suture  which  has  been  employed ; 
I  select  one  which  seems  the  best. 

A  double  row  of  sutures  is  used,  deep  and  superficial. 
(Fig.  46.)  The  peritoneal  covering  is  detached  from  the 
muscular  fibre  for  a  little  distance  along  the  margins  of  the 
wound :  in  this  way,  it  is  possible  to  turn  inwards  a  greater 
surface  of  peritoneum.  Then  the  deep  sutures  are  placed. 
They  are  made  to  enter  at  about  half  an  inch  from  the  edge  of 
the  wound,  passed  obliquely  through  uterine  tissue,  and  made  to 
emerge  near  to  the  bottom  of  the  cut  surface.  No  suture  should 
enter  the  uterine  cavity.  These  deep  sutures  should  be  placed 
about  three-quarters  of  an  inch  apart ;  and  they  should  be 
carried,  converging  a  little,  beyond  the  ends  of  the  incision. 

Then  the  superficial  sutures  are  placed,  two  between  each 
deep  suture.  The  needle  first  pierces  peritoneum  and  muscle, 
coming  out  a  little  below  the  lip  of  the  wound ;  then  it  picks  up 
the  free  edge  of  the  peritoneum  on  its  own  side,  and  finally 
pursues  the  same  course  in  opposite  direction  with  the  other 
*  Der  Kaiseyschnitt,  Sec,  Leipzig,  1882. 


282 


CESAREAN  SECTION. 


side.  The  diagram,  after  Sanger,  shows  this  more  clearly  than 
any  description.  The  sutures  are  placed  with  great  care, 
and  they  are  carried  a  little  way  beyond  the  extremities  of 
the  wound. 

The  superficial  sutures  are  first  tied,  bringing  into  accurate 
apposition  two  strips  of  peritoneum.  Then  the  deep  sutures 
are  tied,  causing  still  further  incurvation  of  serous  surfaces,  and 
closing  up  and  strengthening  the  whole.     Finally,  if  apposition 

does    not     seem 
u  to     be     perfect, 

a  simple  con- 
tinuous suture 
may  be  insert- 
ed over  the 
whole. 

In  every  case 
where  future 
pregnancies 
may  take  place 
this  should  be 
prevented  by 
excising  with 
scissors  a  small 
portion  of  each 
Fallopian  tube. 

While  the  su- 
tures are  being 
inserted,  a  few 
sponges  placed 
in  Douglas's 
pouch  and 
around  the  uterus  will  absorb  any  fluids  that  may  have  escaped. 
These  are  now  removed,  and  the  whole  cavity  cleansed. 

The  wound  in  the  parietes  is  sutured  in  the  ordinary  manner. 

The  question  of  drainage  is  not  without  importance.     In 

most  cases  it  will  be  useless ;   but  in  some,  by  giving  timely 

warning  of  the  escape  of  uterine  fluids,  it  may  prove  invaluable. 


Fig.  46. 

Diagrams  to  show  the  placing  of  Sutures  in  the  Uterine 
Wound  after  Cesarean  Section. 

P,  Peritoneum  ;  F,  Uterine  Fibre ;  M,  Mucous  or  Decidual 
Layer;  U,  Deep  Uterine  Suture;  S,  Superficial  Serous  Suture. 


MODIFICA  TIONS.  283 

At  the  worst  it  is  harmless,  and  therefore  I  should  always  insert 
a  drainage  tube.  It  need  not  go  deeply  into  the  pelvis.  A  piece 
of  rubber  tubing,  cut  obliquely,  laid  over  the  uterine  wound, 
and  fixed  by  a  stitch  into  the  lower  angle  of  the  parietal  in- 
cision, will  suffice.  At  the  end  of  a  day  or  two  it  may  be 
removed,  should  it  not  be  required. 

If  the  patient  survives  the  shock  of  the  operation,  the  chief 
subsequent  danger  is  from  peritonitis.  This  is  treated  according 
to  ordinary  principles  by  turpentine  enemas  and  saline  purges. 
But  such  peritonitis  will  almost  certainly  have  been  produced 
by  extravasation  of  uterine  secretions,  and  for  this  the  best 
treatment  is  free  drainage  and  frequent  irrigation.  At  the  same 
time  cleansing  of  the  vagina  and  of  the  cavity  of  the  uterus  by 
warm  antiseptic  fluids  must  be  instituted.  If  there  is  evidence 
of  gaping  of  the  uterine  wound,  the  abdominal  incision  may  be 
re-opened,  and  an  attempt  made  to  close  it.  If  the  patient 
will  bear  it,  hysterectomy  even  might  be  contemplated  as  a 
last  resource. 

Modifications. — A  few  of  the  most  important  modifications 
may  be  referred  to. 

Kehrer  of  Heidelberg*  recommends  that  the  uterus  be 
opened  at  the  level  of  the  internal  os  by  a  transverse 
incision.  By  this  method  he  thinks  that  the  wound-  is  less 
liable  to  gape,  that  the  placenta  is  less  likely  to  be  in  the  way, 
that  the  head  is  more  easily  reached,  and  that  the  peritoneum, 
being  here  loosely  attached  to  the  uterus,  is  more  easily  sutured 
separately.  He  recommends  vaginal  as  well  as  abdominal 
drainage.  He  lost  three  cases  in  seven  operations,  and  his  plan 
has  not  secured  followers.  Obvious  objections  are :  danger  of 
haemorrhage,  the  wound  being  in  the  region  of  large  vessels ; 
difficulty  in  controlling  it  by  temporary  ligature,  should  it 
occur ;  and  risk  of  circular  tearing  in  extracting  the  child. 

Cohnsteinf  recommended  that  the  whole  uterus  should  be 
turned  out  of  the  abdominal  wound,  and  that  the  opening 
should  be  made  on  its  posterior  aspect  while  the  aorta  is  being 
*  Archiv.f.  Gyndk.,  bd.  xix.,  heft.  2.      t  Centralbl.f.  Gyndk.,  bd.  v.,  heft.  12. 


284  CESAREAN  SECTION. 

compressed.  He  advised  drainage  through  Douglas's  pouch, 
and  complete  closure  of  the  abdominal  wound.  He  rests  the 
advantage  of  his  plan  on  the  facts,  that  the  uterine  tissue  is 
thickest  behind,  and  therefore  less  likely  to  gape ;  and  that  the 
posterior  opening  and  dependent  drainage  are  the  best  safe- 
guards against  septic  peritonitis.  His  plan  has  not  been 
adopted. 

Sanger*  himself  recommended  the  long  abdominal  incision, 
and  delivery  of  the  uterus  before  extracting  the  foetus.  A  few 
sutures  are  at  once  placed  in  the  upper  end  of  the  incision,  to 
prevent  extrusion  of  bowels,  while  the  abdominal  cavity  is  shut 
off  by  placing  a  sheet  of  caoutchouc  under  the  uterus  over  the 
abdominal  wall.  The  evident  disadvantages  of  this  plan 
probably  outweigh  the  advantages. 

Frank!  has  ingeniously  suggested  that  the  vesico- uterine 
pouch  should  be  closed  as  far  as  possible  by  stitching  the  round 
ligaments  together,  and  draining  the  hollow  thus  formed  through 
the  wound.  The  use  of  a  short  rubber  tube  in  the  manner  I 
have  suggested,  secures  this  advantage  by  a  simpler  method. 

*  Archivf.  Gyndk.,  bd.  xix.,  heft.  3,  s.  397. 
t  Centralbl.  f.  Gyndk.,  bd.  v.,  heft.  25,  s.  598. 


Porro's  Operation.    Puerperal  Hysterectomy. 

History. — Removal  of  the  uterus,  as  a  sequel  to  Caesarean 
section,  was  first  deliberately  planned  and  carried  out  by  Porro, 
in  the  Maternity  Hospital  of  Pa  via,  in  1876.  His  patient  was 
a  woman  deformed  by  rickets ;  and,  although  puerperal  fever 
was  then  prevalent  in  the  hospital,  an  excellent  recovery 
followed.  The  idea  was  suggested  by  the  success  of  hyster- 
ectomy for  fibroids,  and  was  strengthened  by  the  results  of 
experiments  upon  animals.  Since  then  the  operation  has  been 
known  by  Porro's  name. 

According  to  Godson,*  the  possibility  of  removing  the  gravid 
uterus  from  animals  was  first  proved,  in  1768,  by  Cavallini  in 
Florence.  In  1828  Blundell  of  Guy's  Hospital  performed  the 
same  operation  on  four  bitches,  with  three  successes,  and 
suggested  that  hysterectomy  might  be  a  wise  practice  after 
Caesarean  section,  or  when  a  patient  is  evidently  sinking  after 
rupture  of  the  womb.  Michaelis  of  Marbourg,  in  1809,  made 
a  like  suggestion  ;  and  other  workers  added  to  the  experimental 
proofs  of  the  possibility  of  operating  with  success. 

The  first  case  of  actual  removal  of  the  gravid  uterus  in  a 
woman  was  in  the  hands  of  Horatio  Storer  of  Boston  in  i86g. 
He  performed  hysterectomy  to  avoid  death  from  incontrollable 
haemorrhage  in  Caesarean  section.  The  patient  died  in  sixty- 
eight  hours.  After  Porro's  own  operation,  the  next  success  was 
secured  by  Spath  of  Vienna,  in  1877.  Since  then  the  operation 
has  been  performed  more  than  250  times,  with  a  per-centage  of 
women  saved  of  something  between  40  and  50. 


THE    OPERATION. 

Porro's    operation    may   be   defined    as    Caesarean    section, 
followed  by  removal  of  the  uterus  at    the   cervical  junction, 
along  with  the  ovaries  and  oviducts.     It   has  been  variously 
*  Brit.  Med.  Journ.,  Jan.  2Cth,  1884. 


286  PORRO'S  OPERATION. 

named — Csesarean  hystero-oophorectomy,  Caesarean  hystero- 
ovariotomy,  puerperal  hysterectomy  :  Porro  himself  described 
it  as  "  Utero-ovarian  amputation,  as  a  mode  of  completing  the 
Caesarean  section."  A  true  Porro's  operation  is  therefore  always 
preceded  by  Caesarean  section.  In  his  proceeding  also  the  foetus 
is  supposed  to  be  viable.  But  puerperal  hysterectomy  may  be 
performed  for  ruptured  uterus,  and  for  abnormal  conditions 
which  exist  before  the  end  of  pregnancy :  it  is  necessary  to 
separate  these  from  true  Porro  operations.  Godson,  in  his 
valuable  paper,  very  properly  tabulates  the  operations  into  : 

1.  True  Porro  operations. 

2.  Utero-ovarian  amputations  performed  during  pregnancy, 
but  before  the  foetus  was  viable. 

3.  Operations  for  removal  of  the  foetus  from  the  abdominal 
cavity  by  laparotomy,  followed  by  amputation  of  ruptured 
uterus  with  ovaries. 

For  each  of  these  proceedings  the  operative  details  are,  in 
their  main  features,  identical.  Some  special  remarks  will,  how- 
ever, be  necessary  in  describing  the  operation  for  ruptured 
uterus. 

The  Parietal  Incision  is  the  same  as  for  simple  Caesarean 
section.  If  anything,  it  ought  to  be  lower,  because  the  stump  of 
the  amputated  uterus  has  to  be  brought  out  at  its  lower  end. 
A  modification  introduced  by  Miiller  in  1878,  whereby  the  whole 
uterus  is  turned  out  of  the  abdomen  before  it  is  opened,  neces- 
sitates a  very  long  incision.  The  advantages  claimed  for  this 
method  are,  that  it  avoids  the  risk  of  escape  of  uterine  fluids 
into  the  abdomen  (a  real  advantage  if,  as  in  his  case,  the  foetus 
is  putrid),  and  that  it  renders  easy  the  application  of  a  temporar}^ 
constrictor  to  prevent  haemorrhage.  The  evident  disadvantages 
are,  however,  so  great  that  Miiller's  modification  has  not  re- 
ceived much  support. 

The  Uterine  [Opening  may  be  made  by  incision  or  by  tearing, 
and  may  be  directed  transversely  or  longitudinally.  As  the 
uterus  is  to  be  amputated,  and  the  uterine  wound  is  not  to  be 


AMPUTATION  OF   UTERUS.  287 

closed,  the  mode  of  opening  is  not  so  important  in  Porro's 
operation  as  it  is  in  true  Caesarean  section.  The  selection  of 
a  site  for  making  the  opening  may,  within  certain  limits,  be 
guided  by  the  position  of  the  placenta. 

Godson  favours  a  transverse  opening  low  down,  made  by 
tearing.  Most  operators,  however,  prefer  a  vertical  opening, 
made  by  cutting ;  and  this  method  seems,  on  the  whole,  to  be 
the  best.  The  incision  may  be  rapidly  made  by  scissors,  in 
the  manner  recommended  for  Caesarean  section. 

Other  details  as  to  the  placing  of  sponges,  pressing  forwards 
the  uterus  and  delivering  the  child,  are  the  same  as  for  that 
operation.  The  cord  is  divided  between  compression  forceps, 
and  the  child  handed  over  to  an  assistant. 

Management  of  the  Placenta. — The  placenta  may  or  may  not  be 
removed  before  amputating  the  uterus.  The  only  advantage  of 
so  removing  it  is,  that  the  uterus  is  thereby  diminished  in  size  ; 
the  disadvantages  are,  waste  of  time  and  risk  of  bleeding. 
Experience  has  proved  that  it  is,  at  least,  unnecessary  ;  practi- 
cally, therefore,  it  may  be  left  attached. 

Control  of  Hemorrhage  from  the  uterus  may  be  effected  by 
temporary  constriction  round  the  neck,  by  the  hand  inserted 
into  the  abdominal  cavity,  or  by  an  elastic  ligature,  or  by  an 
instrument  such  as  Tait's  rope  constrictor.  Large  T-shaped 
compression  forceps  applied  to  the  edges  of  the  uterine  wound 
would  quickly  and  efficiently  serve  the  same  purpose.  But,  with 
moderate  uterine  contraction  and  due  rapidity  of  operation, 
bleeding  from  the  uterine  wound  may  be  ignored — at  least,  till 
the  uterus  is  turned  out  of  the  abdomen. 

The  uterus  is  delivered  by  hooking  the  forefinger  of  each 
hand  into  the  ends  of  the  incision  and  dragging  it  forwards. 
The  abdominal  cavity  is  shut  off  by  placing  large  sponges  in 
the  opening. 

Amputation  of  Uterus.  Treatment  of  Pedicle. — Thus  far  experi- 
ence has  declared  strongly  in  favour  of  the  extra-peritoneal 
treatment  of  the  pedicle.  According  to  Godson's  tables,  of 
fifteen  cases  treated  by  intra-peritoneal  methods,  eleven  died. 


288  PORRO'S  OPERATION. 

Though  the  verdict  thus  given  cannot  be  regarded  as  final, 
it  may  be  safely  concluded  that,  with  the  practical  methods 
at  present  in  vogue,  the  likelihood  of  success  is  greater  with 
the  extra-peritoneal  than  with  the  intra-peritoneal  method. 

Numerous  methods  of  constricting  the  pedicle  have  been 
employed.  Various  forms  of  wire  constrictors  and  chain 
ecraseurs  ;  the  wire  ligature,  singly  or  in  sections ;  steel  clamps  ; 
and  the  elastic  ligature,  have  been  used.  Constriction  by  a 
wire  which  can  be  tightened  has  been  most  favoured,  and  has 
given  the  best  results.  Cintrat's  constrictor  has  most  often  been 
employed;  but  Koeberle's  simpler  and  smaller  instrument  is 
gradually  displacing  it.  Tait's  recent  modification  of  Koeberle's 
serre-noeud  (Fig.  38)  is  as  nearly  perfect  as  such  an  instrument 
can  be ;  and  this  instrument  I  consider  the  most  suitable  for 
securing  the  pedicle  in  puerperal  hysterectomy. 

The  instruction  generally  given  is,  to  place  the  wire  round 
the  neck  of  the  uterus  at  the  level  of  the  internal  os.  But  the 
position  of  the  internal  os  will  vary  according  to  the  stage  of 
labour  and  the  subsequent  degree  of  uterine  contraction.  It 
will  generally  be  safe  to  place  the  wire  immediately  below  the 
bulge  of  the  uterine  walls,  which  marks  the  lowest  descent  of 
the  foetus.  In  the  later  stages  of  labour  this  will  be  very  near 
to  the  level  of  the  external  os.  In  cases  necessitating  opera- 
tion, there  will  be  some  obstruction  to  the  descent  of  the  foetus, 
and  as  the  uterus  contracts  the  os  is  of  necessity  dragged  up 
over  the  foetus.  The  ureters  can  scarcely  be  endangered.  If  a 
temporary  constrictor  has  been  put  on,  the  wire  is  placed  below 
it,  if  this  does  not  involve  too  low  a  situation  ;  but  there  is  no 
strong  reason  why  the  wire  should  not  be  placed  in  the  groove 
of  the  temporary  constrictor,  or  even  above  it.  The  single  wire 
is  quite  sufficient :  extra  ligatures  of  silk  or  other  material  are 
useless,  and  may  act  simply  as  traps  for  filth.  The  instrument 
is  fixed  so  that  the  handle  shall  be  at  right  angles  to  the  wound, 
or  turned  a  little  upwards  towards  the  umbilicus.  In  this  posi- 
tion it  is  least  in  the  way  of  catheterism,  or  dressing  of  wound 
or  pedicle. 

To  fix  the  pedicle  in  the  wound,  and  to  prevent  its  retraction. 


THE  PEDICLE.  289 

one  or  two  round  steel  pins  are  passed  through  it  above  the 
site  of  constriction.  The  pins  are  identical  with  those  used  in 
hysterectomy  for  fibroids,  and  their  ends  are  protected  in  the 
same  way. 

The  uterus  being  cut  off  at  a  distance  of  about  three-quarters 
of  an  inch  above  the  wire,  the  pedicle  is  carefully  placed  in  the 
bottom  of  the  abdominal  incision.  Before  doing  so,  the  vesico- 
uterine cul-de-sac  is  cleansed  with  a  sponge,  and  the  peritoneum 
around  the  pedicle  and  covering  Douglas's  pouch  is  also  cleansed. 
Some  surgeons,  with  a  view  to  getting  as  rapid  and  complete 
closure  of  the  peritoneum  around  the  pedicle  as  possible,  recom- 
mend that  the  parietal  peritoneum  at  the  lower  extremity  of  the 
wound  should  be  fixed  to  the  peritoneum  surrounding  the  pedicle. 
If  this  is  not  done,  it  would  certainly  be  worth  while  to  pull  the 
peritoneum  on  the  abdominal  wall  outwards  over  the  cut  sur- 
faces, and  fix  it  there  by  a  suture  just  above  the  pedicle.  How- 
ever observed,  the  golden  rule  of  peritoneum  to  peritoneum 
ought   never  to  be  neglected. 

The  lowest  suture  in  the  abdominal  wound  is  so  placed  that 
it  brings  the  cut  edges  in  close  apposition  to  the  pedicle,  but 
not  with  undue  tension.  Tension  will  cause  suppuration  around 
the  suture,  an  event  specially  to  be  guarded  against.  The  rest 
of  the  sutures  are  placed  in  the  ordinary  way. 

Except  in  very  special  cases,  drainage  is  not  called  for. 

The  pedicle  is  now  finally  trimmed  and  dresssd.  With 
scissors  any  superfluous  tissue  is  cut  off,  leaving  a  circular 
convex  surface,  even  all  round.  The  mucous  membrane  in  the 
centre,  being  prone  to  decompose,  is  scraped  out,  and  the  cavity 
cleansed.  To  mummify  the  tissue  destined  to  slough  beyond  the 
constricting  wire,  perchloride  of  iron  is  rubbed  into  the  raw 
surface,  either  solid  or  in  a  concentrated  solution  in  glycerine. 
While  this  is  being  done  pieces  of  lint  are  carefull}'  packed 
around  its  base,  so  that  no  discharges  shall  get  inside  the 
abdominal  cavity. 

The  dressing  of  the  wound  is  most  conveniently  carried  out 
in  two  parts.  The  upper  part,  the  parietal  wound,  is  dressed 
as  if  for  primary  union,  with  a  dressing  that  need  not  be  dis- 

20 


290  PORRO'S  OPERATION. 

turbed  for  a  week.  The  part  in  which  the  pedicle  lies  is  so 
covered  that  a  discharge  of  blood  will  be  at  once  visible,  and 
the  screw  of  the  clamp  reached  without  disturbing  the  upper 
dressing.  Further,  the  pedicle,  undergoing  decomposition, 
ought  to  be  kept  apart  from  the  healing  wound,  and  constantly 
under  the  influence  of  active  antiseptics.  -  With  the  help  of 
Listerism,  it  sometimes  happens  that  from  beginning  to  end  the 
pedicle  is  kept  sweet,  even  if  it  does  not  continue  dry :  this  is 
an  advantage  that  cannot  always  be  counted  upon,  however. 
All  around  the  root  of  the  pedicle  small  pledgets  of  boracic  lint 
or  absorbent  gauze  are  packed,  and  removed  as  often  as  may 
be  necessary. 

The  wire  of  the  serre-nceud  is  tightened  a  little  every  day  or 
every  few  days,  as  may  seem  expedient.  At  the  end  of  a  week 
or  a  fortnight,  it  will  come  away  with  the  strangulated  tissue 
above  it. 

The  after-treatment  requires  no  special  comment.  Peritonitis, 
simple  or  septic,  is  the  chief  cause  of  death,  accounting  for  half 
the  mortality.  To  obviate  this  an  empty  state  of  the  bowels  is 
the  best  treatment.  Turpentine  enemas,  and,  as  soon  as  the 
patient  will  bear  it,  a  saline  aperient,  ought  to  be  given. 
Marked  symptoms  of  peritonitis  ought  to  be  promptly  met  by 
abdominal  drainage  and  irrigation  through  the  wound  above 
the  pedicle.  Rectal  alimentation  and  free  stimulation  will  be 
necessary,  particularly  if  there  is  sickness. 


Liapro- Ely  trotomy . 

By  this  operation  (XuTrdpa — flank ;  eXvrpov — vagina)  is  meant 
removal  of  a  foetus  through  incisions  in  the  abdominal  wall  and 
in  the  vagina,  without  opening  the  peritoneum  or  wounding  the 
uterus.  It  is  also  known  as  Gastro-elytrotomy  and  as  Thomas's 
operation. 

History. — This  operation  is  as  much  the  property  of  Gaillard 
Thomas  of  New  York,  as  is  the  operation  just  described  of  Porro. 
Like  the  latter  operation,  laparo-elytrotomy  had  been  proposed 
and  even  carried  out,  after  a  fashion,  years  before  Thomas 
re-introduced  it.  According  to  MangiagaUi,'"  Joergf  in  1806 
suggested  the  plausibility  of  reaching  the  uterus  through  an 
abdomino-vaginal  incision ;  but  there  is  no  evidence  that  he 
ever  operated.  In  1820,  Ritgen,  |  on  hearing  of  the  plan  of 
ligating  the  external  iliac  without  entering  the  peritoneum, 
devised  gastro-elytrotomy  for  removal  of  the  foetus  from  the 
uterus.  He  operated  in  1821  ;  but  the  bleeding  was  so  free  that 
he  had  to  conclude  with  an  ordinary  Csesarean  section.  The 
patient  died  of  vaginal  haemorrhage.  Baudelocque  (1823) 
seems  to  have  devised  no  fewer  than  six  methods,  of  which  he 
tried  two,  both  without  success.  Physick  (1824)  proposed  a 
somewhat  similar  proceeding,  reaching  the  uterus  by  a  hori- 
zontal incision  over  the  top  of  the  bladder  and  under  the 
peritoneum  ;  but  he  never  put  it  into  practice.  Sir  Charles  Bell 
(1837)  discussed  the  method  of  sub-peritoneal  hysterotomy,  and 
suggested  digital  laceration  of  the  vagina  to  avoid  haemorrhage  ; 
but  it  is  doubtful  if  his  proposal  was  original. 

The  operation  owes  its  revival,  and  indeed  its  present  exist- 
ence, to  Thomas.  His  proceeding,  that  of  Ritgen  and  Bell 
combined,  was  carried  out  by  him  in  March,  1870,  on  a  living, 
or  rather  a  dying,  woman.  §      The  patient  was  at  the  end  of  the 

*  "  Le  piu  recenti  Mod.  del  Taglio  Cesareo,"  Ajit.  Jouvn.  Med.  Sc,  July,  1884. 

t  Handbiuh  der  Gebitrtshulfe,  1807.     Garrigues. 

\  Heidelberg  Klinische  Annalen,  vol.  i.,   1825,  p.  226, 

§  Am.  Journ.  Obstet.,  May,   1870. 

20  - 


292  LAPARO-ELYTROTOMY. 

seventh  month  of  gestation,  and  was  in  articulo  mortis  from  pneu- 
monia;  the  operation  was  undertaken  solely  in  the  interests  of 
the  child.  This  case  proved  the  feasibility  of  the  operation. 
Dr.  Skene*  and  others  took  it  up,  and  have  secured  to  it  a 
promising  degree  of  success. 


THE    OPERATION. 

Dr.  H.  J.  Garrigues,  of  New  York,  has  devoted  special 
study  to  the  history  and  technique  of  the  operation,  and  has 
minutely  described  the  anatomy  of  the  parts.!  To  him  and  to 
Harris  of  Philadelphia,  as  well  as  to  Thomas  himself,  I  am 
mainly  indebted  for  the  following  description. 

Preliminary  Steps. — The  patient  is  prepared  in  the  ordinary 
way  by  clearing  the  primae  viae ;  the  parts  are  thoroughly 
cleansed,  the  pubes  shaved,  and  the  vagina  and  vulva  purified. 
The  pelvis  is  elevated  by  a  hard  cushion,  and  the  thighs  are 
extended  as  much  as  possible.  The  os  uteri,  if  not  fully  dilated, 
is  now  dilated  artificially  by  means  of  Barnes's  bags,  or,  if 
necessary,  by  the  fingers. 

As  the  vagina  communicates  with  the  wound,  complete 
asepticism  is  impossible ;  therefore,  the  antiseptic  spray  may 
be  dispensed  with. 

Assistance. — Four  assistants  are  desirable.  The  operator 
stands  on  the  right  of  the  patient.  One  assistant  is  placed  on 
the  left  side ;  his  duty  is  to  pull  the  fundus  backwards  and 
towards  the  left,  so  tilting  the  lower  end  of  the  uterus  forwards 
and  towards  the  right,  and  making  tense  the  skin  in  the  right 
groin.  A  second  assistant,  standing  on  the  right  side  and  to 
the  operator's  left,  keeps  open  the  wound  in  the  groin  by 
pressing  his  hand  into  its  upper  edge,  and  drags  the  peritoneum 
and  bowels  upwards.  A  third  assistant  passes  a  catheter  into 
the  bladder,  and  manipulates  it   according  to  direction.     The 

t  New  York  Med.  Journ.,  Oct.  and  Nov.,  1878. 
*  Am.  Journ.  Obstet.,  Oct.,  1887. 


PARIETAL  INCISION.  293 

fourth  assistant  helps  in  various  ways,  chiefly  in  pushing  the 
vagina  into  the  wound,  and  in  manipulating  the  thermo-cautery 
should  it  be  called  for. 

The  Parietal  Incision  is  made  in  the  right  inguinal  region, 
which  has  a  slight  advantage  over  the  left  in  being  more  remote 
from  the  rectum.  It  is  slightly  curved,  concavity  upwards,  and 
runs  parallel  with  Poupart's  ligament,  about  an  inch  above  it. 
It  begins  an  inch  and  three-quarters  above  and  to  the  outside 
of  the  spine  of  the  pubes,  and  ends  an  inch  above  the  anterior 
superior  spine  of  the  ilium.  The  incision  thus  escapes  the 
internal  epigastric  artery  and  the  round  ligament  on  the  inside; 
it  divides  the  external  epigastric.  The  external  oblique  muscle 
is  divided  through  its  aponeurosis,  except  just  above  the  iliac 
spine,  where  muscular  fibres  are  met  with.  The  fibres  of  the 
internal  oblique  being  parallel  to  the  incision,  are  simply  sepa- 
rated ;  the  fibres  of  the  transversalis  descending  a  little,  require 
division.  The  transversalis  fascia  is  now  reached  and  carefully 
divided,  after  being  pinched  up  between  forceps.  The  fingers 
now  push  upwards  the  peritoneum  and  sub-peritoneal  fat,  and 
slowly  work  downwards  towards  the  vagina,  which  is  mean- 
while tilted  upwards  and  to  the  right  by  the  assistant  manipu- 
lating the  fundus. '  The  circumflex  ihac  is  below  the  incision  and 
cut  of  the  way.  The  elevated  and  loosely  attached  peritoneum 
is  easily  pushed  aside  and  kept  out  of  the  way  by  the  assistant 
behind  the  operator,  using  the  palms  of  his  hands  covered  by 
linen  rags  wrung  out  of  warm  carbolic  lotion.  A  straight  silver 
catheter  is  now  passed  into  the  bladder  by  the  third  assistant, 
and  its  tip  made  to  bulge  at  the  vesico-vaginal  junction  on  the 
right  side,  so  as  to  mark  the  proximity  of  bladder  and  ureter. 

The  Vaginal  Opening. — At  the  end  of  pregnancy,  in  cases  of 
narrowed  diameter,  the  whole  of  the  uterus  will  lie  above  the 
brim ;  and  during  labour,  as  the  head  cannot  descend,  the 
vagina  will  be  dragged  upwards.  Near  the  utero-vaginal  junc- 
tion vessels  are  most  abundant  ;  it  is  therefore  advisable  to 
make  the  opening  in  the  vagina  as  low  down  as  possible.     The 


294  LAPARO-ELYTROTOMY. 

vaginal  branch  of  the  uterine  artery  at  the  side  of  the  vagina, 
and  the  ureters  and  base  of  the  bladder  in  front,  leave  the 
antero-lateral  aspect  of  the  vagina  as  the  most  eligible  site  for 
making  the  opening.  The  ureter  and  base  of  the  bladder  lie 
most  dangerously  near,  almost  in  the  field  of  operation. 
Roughly  speaking,  the  ureter  enters  the  bladder  an  inch  below 
the  level  of  the  external  os  in  the  later  stages  of  pregnancy ;  and 
during  labour  in  the  normal  state,  shown  in  the  dissection  which 
I  have  made  (Fig.  45),  the  relations  are  not  much  disturbed. 
From  its  entrance  into  the  base  of  the  bladder,  a  position  which 
may  be  demonstrated  by  the  catheter,  the  ureter  crosses  over 
the  vagina  obliquely  upwards  and  backwards.  The  site  of 
election  ought  to  be  at  least  an  inch  and  a  half  below  the  level 
of  the  tip  of  the  catheter,  lower  if  possible,  and  a  clear  inch 
from  the  lateral  margin  of  the  bladder. 

The  vagina  may  be  pushed  into  the  wound  in  various  ways. 
Garrigues  recommends  for  this  puapose  a  blunt  wooden  instru- 
ment, something  like  the  obturator  of  a  cylindrical  speculum  ; 
and  he  directs  that  the  incision  should  be  made  on  this  instru- 
ment as  low  down  as  possible,  away  from  the  uterus,  and 
parallel  to  the  catheter  in  the  bladder.  Thomas,  in  his  first 
case,  used  a  steel  sound  ;  in  his  second  case,  the  finger  of  an 
assistant  pushed  up  the  vagina.     Skene  used  his  own  finger. 

The  advantage  of  using  the  wooden  obturator  is,  that  the 
parts  may  be  divided  on  it  by  the  cautery ;  the  disadvantage  is, 
that  the  division  is  made  without  the  diagnostic  aid  of  touch. 
Probably  as  good  a  plan  as  any  would  be  that  the  operator 
should  push  the  vagina  into  the  wound  by  the  first  and  second 
fingers  of  the  right  hand,  and  with  the  left  hand  push  a  Lister's 
sinus  forceps  through  the  vagina  between  them.  Dilating  the 
blades  sufficiently  to  admit  the  two  fingers  of  the  right  hand, 
the  surgeon  may  enlarge  the  opening  by  tearing  with  the  fingers 
inside  and  outside  the  vagina.  The  direction  which  the  rent 
tends  to  pursue  must  be  observed ;  as  far  as  possible,  it  is 
guided  downwards  and  backwards,  away  from  bladder  and 
ureter.  It  is  not,  however,  at  this  stage  that  these  parts  are  in 
most  danger ;  but  later,  during  the  extraction  of  the  child. 


DELIVERY  OF  THE   CHILD.  259 

Delivery  of  the  Child. — The  catheter  is  withdrawn,  and  steps 
are  now  taken  to  extract  the  foetus.  The  finger  is  hooked  into 
the  OS  uteri,  pulling  it  towards  the  wound.  If  dilatation  is  not 
sufficiently  advanced,  this  is  artificially  encouraged  by  the 
fingers.  The  membranes  are  ruptured ;  the  long  axis  of  the 
uterus,  by  combined  depression  of  the  fundus  and  elevation  of 
the  cervix,  is  brought  as  far  as  possible  in  a  line  with  the 
opening  in  the  flank ;  and  the  child  is  delivered  by  forceps,  or 
turning,  as  seems  at  the  time  most  suitable.  The  placenta  is 
expelled  by  pressure. 

The  child  is  handed  to  an  assistant,  and  attention  directed 
to  the  wound.  Firstly,  all  bleeding  must  be  checked.  The 
edges  of  the  vaginal  rent  are  examined  carefully,  and  ligatures 
placed  on  bleeding  points.  A  large  sponge  placed  high  up  in 
the  vagina  may  be  of  service  in  pushing  the  parts  into  the 
wound.  Thornton's  T-shaped  forceps  may  be  found  of  value  in 
checking  oozing  over  considerable  areas.  Temporary  forci- 
pressure  may  be  found  of  conspicuous  advantage.  The  applica- 
tion of  the  actual  cautery  through  a  vaginal  speculum  may  be 
required.  As  a  last  resource,  sponge  packing  from  vagina  and 
from  wound  with  firm  pressure  by  bandages  may  be  used. 

Finall}^,  the  safety  of  bladder  and  ureter  must  be  ascertained. 
If  the  ureter  cannot  be  seen,  it  is  probably  intact.  A  rent  in 
the  bladder  may  easily  be  overlooked ;  the  best  way  to  detect  it 
is  to  inject  coloured  fluid  through  the  urethra. 

Cleansing,  Stcturing,  and  Dressing. — The  wounds  are  thoroughly 
cleansed  by  irrigation  and  sponging ;  iodoform  powder  is  blown 
into  the  deep  parts,  and  one  or  two  large  drainage  tubes  are 
passed  through  the  vaginal  opening  into  the  wound  in  the  loin, 
and  out  to  the  abdominal  surface. 

The  parietal  wound  is  closed  in  the  ordinary  way.  If  the 
abdomen  is  compressed  by  a  binder  the  peritoneum  will  fall 
down  into  its  natural  position,  and  the  gaping  wound  will  fall 
together.  If  necessary,  irrigation  may  be  carried  out  through 
the  drainage  tubes. 

The  dressings  over  the  flank  may  be  of  any  antiseptic  and 


296  LAPARO-ELYTROTOMY. 

absorbent  material.  On  the  vaginal  aspect  most  scrupulous 
cleanliness  must  be  observed.  Packing  the  vagina  with  dress- 
ings is  irritating  to  the  patient,  and  liable  to  cause  disturbance 
of  parts.  Dressings  packed  between  the  labia  and  around  the 
external  parts  will  be  found  efficient.  The  urine  should  be 
draAvn  at  each  dressing,  three  or  four  times  daily ;  the  external 
parts  ought  then  to  be  cleansed  most  thoroughly,  and  smeared 
with  an  antiseptic  material,  such  as  boro-glyceride ;  and  a  fresh 
dressing  applied,  and  retained  by  a  T  bandage.  A  large  drain- 
age tube  in  the  vagina  will  facilitate  the  outflow  of  the  dis- 
charges. 


Comparative  Survey  of  the  Csesarean,  Porro's,  and 
Thomas's   Operations. 

It  will  be  of  advantage  to  consider  in  conjunction  certain 
facts  and  theories  which  are  common  to  these  modes  of  operative 
delivery.  Though  I  believe  that,  in  some  degree,  each  oper- 
ation has  special  indications,  yet  in  most  cases  the  choice,  qua 
operation,  is  evenly  balanced  ;  that  is  to  say,  a  surgeon  would 
be  fully  justified  in  selecting  any  one  of  them. 

INDICATIONS     TO     OPERATE. 

In  a  general  way  the  indications  to  Caesarean  section  are  the 
indications  to  Porro's  and  to  Thomas's  operations. 

The  most  frequent  indication  is  deformity  of  the  pelvis, 
with  contraction  of  its  diameters.  The  operation  is  said  to 
be  justifiable  when  the  contraction  is  so  great  that  we  cannot 
expect  to  deliver  the  foetus  per  vias  natiirales,  with  or  without 
embryotomj^,  and  save  the  mother.  The  degree  of  contrac- 
tion is  generally  stated  as  ij  inch  and  below.  But  cases  in 
which  much  distortion  exists  may  have  an  upward  limit  of 
2  inches. 

Tumours  of  various  sorts  may  so  block  the  pelvic  outlet  that 
delivery  is  impossible.  Ovarian  and  uterine  growths  of  all 
sorts — enchondromatous  and  other  tumours  springing  from  the 
pelvic  bones,  and  even  tumours  springing  from  the  abdominal 
organs,  as  the  kidney  or  liver — may  cause  the  obstruction. 

Malignant  disease  of  the  cervix,  if  far  advanced,  may  be  an 
indication  for  operation.  Before  the  child  is  viable,  removal  of 
the  whole  uterus  may  be  instituted  ;  but  this  proceeding  comes 
under  a  different  category. 

Impaction  of  the  foetus  transversely  across  the  pelvic  brim 
may,  under  special  conditions,  be  considered  an  indication. 
According  to  Harris,*  seven  out  of  eleven  cases  of  Caesarean 
section  for  impaction  were  saved. 

*  Internat.  Cyc.  Surg.,  vol.  vi.,  p.  762. 


2.98  THE   OPERATIONS   COMPARED. 


MORTALITY    STATISTICS. 

Simple  Casarean. — To  get  at  trustworthy  statistics  of  the  results 
of  the  old  Caesarean  operation  is  impossible.  Mayer's  statistics 
of  the  results  in  England,  Germany,  France,  Belgium,  Italy,  and 
America  give  1605  operations,  with  54  per  cent,  of  recoveries. 
The  infant  recoveries  are  between  50  and  60  per  cent.  Radford's 
table  of  operations  in  Great  Britain  gives  131  cases,  with  only 
23  recoveries.  In  America,  Harris  gives  124  operations,  with  53 
recoveries;  and  other  writers  give  a  per-centage  of  recoveries,  in 
America,  of  about  42  per  cent.  Against  these  statistics  we  must 
place  the  authorised  statements  that  in  certain  hospitals  in  Paris, 
Berlin,  and  Vienna,  not  a  single  success  had  been  scored  for 
many  years.  Too  ready  deductions  have  been  made  from  such 
statements :  the  operation  is  not  uniformly  fatal ;  or  fatal  in 
anything  like  99  per  cent,  of  all  cases.  The  greatest  success 
has  always  attended  the  operation  in  country  districts.  But  on 
the  other  hand,  it  is  certain  that  the  general  statistics  of  results 
are  too  favourable.  A  fair  estimate  would  probably  be  between 
75  and  80  per  cent,  of  deaths  in  all  cases  operated  on  by  the 
old  Caesarean  method. 

The  Improved  Casarean. — The  results  of  the  new  Caesarean 
operation  are  so  favourable  that  it  must  replace  the  old.  Up  to 
the  present,  according  to  Harris,'''  153  Sanger-Leopold  opera- 
tions have  been  performed  in  eleven  countries,  with  a  mortality 
of  29  per  cent.  Crede  records  23  cases,  with  4  deaths.  Twenty 
operations  in  the  Dresden  Institution  had  only  two  deaths,  and 
all  the  children  were  saved ;  six  at  the  Leipzig  clinic  were  all 
successful.  In  Germany,  the  general  mortality  over  75  opera- 
tions is  only  14.7  per  cent.  In  1886  there  were  22  operations, 
with  4  deaths.  In  1887-88,  with  93  operations,  the  mortality 
has  been  25  per  cent. ;  so  that  it  has  not  improved  so  much  in 
proportion  as  Porro's  operation. 

Porro's  Operation. — The  most  complete  Porro-Caesarean  sta- 
tistics are  published  in  the  American  Journal  of  the  Medical  Sciences 
*  Personal  communication. 


MORTALITY.  299 

of  April,  1885.  They  continue  Godson's  table,  and  include 
other  cases.  The  total  is,  164;  Porro's  method,  unmodified,  was 
employed  in  log  of  these,  and  46  patients  recovered.  The 
Porro-Miiller  modification  was  employed  in  41  cases,  with  21 
recoveries.  Veit's  intra-peritoneal  method  of  treating  the  stump 
was  followed  in  14  cases,  with  4  recoveries.  Excluding  mori- 
bund cases,  and  including  only  such  as  may  be  legitimately 
described  as  Porro-Caesarean,  we  have  a  total  of  147  operations, 
with  65  recoveries — a  per-centage  of  women  saved  of  44.  In 
special  institutions  and  in  the  hands  of  special  operators  better 
results  are  got.  Braun  in  12  cases  had  8  recoveries.  Fehling 
had  I  death  in  4  cases ;  he  puts  the  general  mortality  of  the 
Porro-Caesarean  operation  at  55.8  per  cent.  Harris's  latest 
statistics*  give  250  operations  in  fifteen  countries,  with  a  mor- 
tality of  46  per  cent.  In  1885-86-87-88  there  have  been  79 
operations,  with  a  mortality  of  ig  per  cent. — a  very  decided 
improvement,  if  it  is  true.  Curiously,  the  results  of  the  im- 
proved Csesarean  are  best  in  Germany ;  while  Porro's  operation 
has  best  results  in  England.  I  am  inclined  to  believe  that  this 
may  arise  from  earlier  operation  on  the  Continent  than  with  us. 

Laparo-Elytrotomy. — So  far  as  I  can  discover,  only  14  of  these 
operations  have  been  performed,  with  7  maternal  recoveries. 
Of  these,  Skene  of  Brooklyn  has  had  4  cases,  with  3  recoveries. 
From  this  small  number  no  conclusions  can  be  drawn.  It  should 
be  noted,  however,  that  nearly  all  the  deaths  were  in  very 
unfavourable  cases.  On  the  other  hand,  one  of  the  successes 
was  secured  by  Dr.  McKim,f  under  circumstances  almost  as 
unfavourable  as  it  is  possible  to  conceive. 

In  every  case  it  must  be  remembered  that  delay  in  operation 
is  one  of  the  most  potent  factors  in  causing  failure.  Statistics 
show  this  very  markedly.  Operation  at  full  term  before  labour 
has  set  in  cannot  fairly  be  compared  with  operation  at  the  end 
of  an  exhausting  labour,  complicated  perhaps  with  instrumental 
proceedings. 

*  Personal  communication. 
t  N.  Y.  Med.  Journ.,  Dec.   loth,  1887. 


300  THE   OPERATIONS  COMPARED. 


PECULIARITIES    AND    RESULTS    OF    EACH    OPERATION. 

In  seeking  to  form  a  fair  comparison  of  the  relative  values  of 
these  operations,  many  circumstances  must  be  taken  into  con- 
sideration. Among  these  the  most  important  are  :  the  facility 
of  the  operation ;  the  nature  of  the  immediate  risks  as  to  shock, 
bleeding,  and  peritonitis ;  and  the  character  of  the  remote 
effects. 

The  Operation. — From  the  nature  of  the  case,  many  operations 
have  to  be  suddenly  performed  by  practitioners  not  specially 
trained,  with  an  inadequate  supply  of  instruments,  and  at  a 
distance  from  skilled  assistance.  In  such  cases  the  classical 
Csesarean  operation  will  almost  certainly  be  selected.  In  every 
case,  however,  the  improved  suturing  of  the  uterine  wound 
ought  to  be  carried  out. 

In  other  circumstances,  where  the  full  advantages  of  trained 
assistance,  suitable  instruments,  and  some  experience,  are  avail- 
able, it  is  not  easy  to  decide,  from  the  operator's  standpoint, 
which  is  the  most  promising. 

Of  laparo-elytrotomy,  all  who  have  performed  the  operation 
say  that  it  is  easier  than  Caesarean  section,  that  it  presents  no 
special  difficulties,  and  requires  no  special  instruments.  From 
the  fact  that  Skene  was  able  to  finish  one  operation  in  fifteen 
minutes,  and  another  in  ten,  it  is  evident  that  the  technique  is 
not  elaborate  or  difficult.  The  greatest  risk  is  rupture  of  the 
bladder ;  this  happened  in  five  of  the  cases,  but  the  rent  healed 
spontaneously  in  all.  Bleeding  has  given  little  trouble.  Pelvic 
cellulitis  is  to  be  apprehended  from  the  extensive  opening  up  of 
fibrous  layers  and  bruising  of  parts ;  and  a  somewhat  prolonged 
suppuration  is  to  be  expected.  The  immediate  dangers  are 
over  when  the  vaginal  haemorrhage  has  been  controlled.  The 
bladder  is  liable  to  be  abnormally  placed  in  these  cases ;  and  if 
its  situation  can  be  diagnosed  before  operation,  the  side  opposite 
to  that  where  its  chief  bulk  lies  should  be  selected  for  operation. 
It  is  of  great  assistance  to  have  the  os  uteri  fully  dilated  before 


SHOCK.  301 

operation.  Indeed,  a  hard  contracted  os  is  a  contra-indication 
if  the  patient's  condition  is  so  bad  that  time  cannot  be  safely 
given  to  make  dilatation. 

It  may  be  true  that  laparo-elytrotomy  is  easier  than  Caesa- 
rean  section ;  but  on  the  face  of  it  this  does  not  seem  to  be  the 
case.  The  making  of  the  wound  in  the  groin  seems  a  formid- 
able and  somewhat  difficult  proceeding ;  and  the  division  of  the 
vaginal  wall  looks  delicate,  if  not  difficult ;  while  the  amount  of 
laceration  by  the  forthcoming  child  is  uncertain  and  may  be 
hazardous.  It  is  more  than  likely  that  the  difficulties  are 
apparent  rather  than  real ;  it  is  certain  that  the  appearance 
of  difficulty  has  deterred  many  from  operating  by  this  method. 

In  Csesarean  section  there  is  no  real  difficulty.  Bleeding 
from  the  uterine  wound  may  be  momentarily  alarming. 
Adroitness  is  necessary  to  prevent  escape  of  uterine  fluids 
into  the  peritoneum.  Patience  and  delicacy  are  essential  in 
closing  the  uterine  wound.  As  compared  with  many  abdominal 
operations,  simple  Caesarean  section  is  easy  and  straightforward. 
The  Sanger  Csesarean  demands  care  and  forethought,  but  can 
scarcely  be  described  as  difficult. 

Porro's  operation,  as  a  piece  of  surgical  work,  is  also  easy. 
The  difficulties  are  mainly  In  the  management  of  the  pedicle. 
A  skilled  surgeon  may  with  perfect  confidence  dispense  with 
temporary  constriction,  and  will  at  the  first  attempt  accurately 
place  the  wire  of  the  serre-nceud.  When  this  has  been  done, 
the  other  steps  are  simple  enough.  The  case  is  not  completed, 
however,  till  the  constrictor  has  been  removed,  and  accidents 
are  to  be  apprehended  while  it  remains  attached. 

From  the  operative  standpoint,  therefore,  there  is  little  to 
weigh  in  favour  of  any  one  proceeding. 

Shock. — The  condition  of  the  patient  at  the  time  of  operation 
is  the  main  factor  in  influencing  results.  If  the  patient  is  ex- 
hausted by  a  prolonged  and  futile  labour,  an  operation  which 
of  necessity  is  prolonged  or  is  attended  with  great  shock  is 
forbidden.  In  respect  of  shock  immediately  produced,  Porro's 
operation  must  come  first ;  so  far  as  time  spent  over  the  opera- 


302  THE   OPERATIONS   COMPARED. 

tion  can  influence  the  result,  Thomas's  operation,  in  which  it 
may  be  necessary  to  dilate  a  rigid  os  uteri,  is  worst.  In  average 
cases,  the  facts  that  Thomas's  operation  may  be  finished  in  ten 
minutes,  that  it  does  not  expose  the  peritoneum,  wounds  only 
cutaneous  or  unimportant  structures,  and  that  the  child  is 
extracted  from  the  womb  in  the  natural  way,  tell  strongly  in 
its  favour.  As  productive  of  collapse,  the  Porro-Miiller  modifi- 
cation is  most  to  be  deprecated.  Csesarean  section  would  seem 
to  hold  a  middle  position. 

HcBinorvhage. — The  danger  from  haemorrhage,  both  immediate 
and  remote,  is  greatest  in  Porro's  operation.  In  a  good  many 
cases,  wire  or  chain  constrictors  have  been  found  inefficient  in 
checking  bleeding  from  the  pedicle,  and  other  extraordinary 
means  have  had  to  be  adopted.  In  ordinary  Caesarean  section, 
haemorrhage  has  not  infrequently  proved  fatal ;  one  of  the 
earliest  hysterectomies  had  to  be  performed  on  account  of  bleed- 
ing. If  the  placenta  is  wounded,  the  danger  is  increased.  If  the 
uterus  contracts  well,  bleeding  is  not  likely  to  be  dangerous ;  if 
it  does  not  contract,  it  would  probably  be  wise  to  finish  by 
hysterectomy.  In  Thomas's  operation,  the  risks  of  bleeding  are 
small ;  the  drawback  is,  if  it  does  occur,  that  it  may  be  difficult 
to  control.  The  vaginal  rent  may  be  indefinitely  increased  by 
the  withdrawing  of  the  foetus,  and  bleeding  may  go  on  at  the 
extreme  ends  of  the  tear.  But  the  torn  vessels  are  not  of  large 
size,  and  simple  means  will  compress  them. 

Peritonitis. — The  large  proportion  of  deaths  from  inflammations 
of  the  peritoneum,  usually  septic,  following  Caesarean  section 
was  one  of  the  strongest  reasons  adduced  by  Porro  for  the  intro- 
duction of  hysterectomy.  But  his  operation  has  not  done  away 
with  this  danger;  in  spite  of  all  precautions,  peritonitis  kills  i6 
per  cent,  of  all  cases  operated  on  by  Porro's  method.  In  laparo- 
elytrotomy  peritonitis  has  only  once  appeared  among  the  causes 
of  death,  and  with  proper  care  its  occurrence  ought  to  be  rare. 

Occurrence  of  future  Pregnancies. — Too  much  has  been  made  of 
the  fact  that  in  Porro's  operation  the  possibility  of  future  preg- 


SPECIAL    CONSIDERATIONS.  303 

nancies  has  been  done  away  with.  In  the  face  of  other  and 
simpler  means,  it  is  a  ridiculous  overdoing  of  surgery  to  ampu- 
tate the  whole  uterus  and  ovaries  to  prevent  the  possibility  of 
conception.  In  Caesarean  section,  it  is  a  very  simple  matter  to 
carry  out  the  suggestion  that  Blundell  made  many  years  ago,  to 
cut  out  two  little  pieces  of  the  Fallopian  tubes :  this  would  put 
the  Caesarean  section,  in  that  respect,  on  a  level  with  Porro's 
operation.  In  Thomas's  operation,  the  possibility  of  future 
pregnancies  is  in  no  way  interfered  with. 

The  final  word  has  yet  to  be  spoken  as  to  the  relative  values 
of  these  operations.  It  may  here  be  said  that  the  results  of 
Porro's  operation  have  not  been  up  to  expectation,  but  show 
signs  of  improvement ;  that  the  improved  Caesarean  section 
has  been  successful  beyond  expectation  ;  and  that  Thomas's 
operation  has  made  out  for  itself  an  extremely  good  position, 
warranting  further  trial.  Beyond  this,  it  may  be  permissible 
to  go  in  the  direction  of  pointing  out  special  indications  and 
centra-indications  for  each  of  the  operations. 


SPECIAL    INDICATIONS    AND    CONTRA-INDICATIONS. 

Laparo-elytrotoviy. — Garrigues  has  mentioned,  as  contra-indi- 
cations  to  this  operation — 

(i)  The  impossibility  of  repeating  the  operation  on  the 
same  side. 

(2)  Impaction  of  the  head  in  the  pelvis. 

(3)  The  presence  of  a  large  tumour  in  the  vagina. 

(4)  An  obstruction  in  the  womb  itself  (as,  malignant  dis- 

ease of  the  cervix). 

(5)  Atresia  or  considerable  narrowing  of  the  vagina. 

Stadfelt  of  Copenhagen  has  added  another  objection  to  the 
operation ;  namely,  a  tumour  arising  from  the  anterior  wall  of 
the  pelvis,  and  pushing  the  vagina  backwards. 

It  would  be  considered  an  unfavourable  condition  if  the 
thighs  were  bent  and  anchylosed,  or  so  distorted  that  they 
obstruct  the  site  of  operation  in  the  groin."    Cicatrices  in  the 


304  THE   OPERATIONS  COMPARED. 

groin  or  pelvis,  indicating  old  or  deep-seated  suppuration,  are 
unfavourable,  but  not  strongly  so. 

The  indications  may  be  considered  favourable  if,  with  an 
absence  of  the  above  conditions,  there  is  present  a  fully  dilated 
or  readily  dilatable  os  uteri ;  if  the  vagina  is  capacious  and  free 
from  heat  or  congestion,  and  has  not  been  bruised  or  injured  by 
previous  manipulations  ;  and  if  the  patient  is  in  a  fair  condition 
of  general  health.  Profound  exhaustion  from  the  labour  is 
against  Porro's  operation,  and,  according  to  most  writers,  would 
tell  less  against  laparo-elytrotomy  than  against  the  Caesarean 
section. 

Porro's  Operation. — Hysterectomy  is  indicated  in  cases  of 
uterine  fibroid  complicating  labour.  It  is  further  specially  indi- 
cated in  cases  where  the  Caesarean  cannot  be  completed :  such 
are,  free  bleeding  from  the  uterine  wound;  inertia  of  the  uterus, 
with  bleeding  from  the  site  of  the  placenta  ;  difficulty  in  detach- 
ing the  placenta;  tendency  to  inversion  of  the  uterus.  In  great 
and  incurable  atresia  vaginae,  Porro's  operation  is  to  be  advised, 
because  the  uterine  discharges  after  Caesarean  section  have  not 
free  exit.  Putridity  of  the  uterine  contents  is  an  indication  for 
Porro's  operation. 

It  is  contra-indicated  in  cases  of  great  exhaustion,  where  the 
shock  of  hysterectomy  would  endanger  the  patient's  life.  In 
cancer  of  the  uterus,  Porro's  operation  ought,  if  possible,  to  be 
converted  into  complete  hysterectomy ;  otherwise,  Caesarean 
section  is  perhaps  preferable. 

Cesarean  Section. — In  all  cases  of  tumour  occupying  the  body 
of  the  uterus,  Caesarean  section  is  inadvisable.  Otherwise,  there 
is  scarcely  a  condition  in  which  operative  delivery  may  be 
called  for  where  this  operation  is  not  feasible.  It  has  the 
widest  primary  applicability  of  the  three.  But  during  the 
progress  of  the  operation  certain  conditions — as,  uterine  inertia, 
haemorrhage,  abnormal  adhesion  of  the  placenta — may  be  met 
with  which  render  it  advisable  to  complete  the  operation  by 
Porro's  method.     Other  conditions  discovered  during  operation 


GENERAL   CONSIDERATIONS.  305 

— such,  for  instance,  as  disease  of  the  uterine  appendages — 
may  suggest  completion  of  the  proceeding  by  hysterectomy. 
A  wound  in  the  uterus  which  does  not  promise  to  be  easily 
or  satisfactorily  sutured  is  a  contra-indication  to  the  simple 
Caesarean  conclusion. 

It  is,  in  fact,  one  great  advantage  of  operating  by  median 
abdominal  section,  that  the  surgeon  can  finish  by  the  improved 
Caesarean  method  or  by  Porro's,  as  seems  at  the  time  most 
suitable. 


21 


Abdominal  Section  for  Rupture  of  the  Uterus. 
Puerperal  Laparotomy. 


ANATOMICAL    CONDITIONS. 

Rupture  of  the  pregnant  uterus  may  take  place  at  any  period 
of  gestation  from  the  third  month  onwards.  It  may  arise 
spontaneously,  or  at  least  without  apparent  cause  ;  also  after 
violent  strains  or  falls,  or  exhausting  occupation ;  but  in  most 
cases  rupture  takes  place  at  full  term,  and  on  the  advent  of 
labour.  Here  we  need  not  discuss  the  somewhat  unsettled 
question  as  to  its  exact  etiology. 

Barnes''"  gives  the  following  classification  of  the  varieties 
of  rupture. 

*'  I.  Rupture  or  hivsting  occurs  when,  under  strong  tension  of 
the  uterus  upon  its  unyielding  contents,  its  walls  burst  more  or 
less  suddenly  in  the  body  or  cervix. 

"  2.  Laceration  or  rent  occurs  when  a  breach  begins  at  the 
edge  of  the  os  uteri,  and  extends. 

"  3.  Grinding  or  crushing  occurs  when  the  uterus  is  subjected 
to  long  compression  between  the  child's  head  and  the  pelvic 
,wall. 

"4.  Perforation  or  boring  through  occurs  when  tissues  give  way 
from  disease  or  long  compression  at  one  point,  or  from  penetra- 
tion by  a  spike  of  bone  or  by  instruments. 

"5.  Avulsion. — The  uterus  has  been  torn  away  by  manual 
force." 

In  rapture  or  bursting  at  full  term,  either  during  labour  or 
before  labour  has  properly  set  in,  we  usually  find  that  the 
whole  ovum,  membranes  and  all,  is  thrown  bodily  into  the 
abdominal  cavity.  The  os  may  be  undilated.  The  rent  rarely 
takes  place  through  the  body  or  fundus,  but  almost  always  near 
the  cervix  or  in  the  lower  segment. 

*  Ohstet.  Med.  and  Surg.,  vol.   ii.,  p.   312. 


SYMPTOMS.  307 

Laceration  in  the  great  majority  of  cases  is  associated  with 
some  obstruction  to  labour.  The  Hquor  amnii  has  usually 
escaped,  and  the  uterus  is  closely  contracted  on  the  child. 
The  uterine  tissue  may  be  torn  away  from  its  attachment  to  the 
cervix,  and  the  laceration  is  then  transverse.  Complete  annular 
divulsion  of  the  cervix  may,  under  these  circumstances,  be 
observed.  Another  mode  of  laceration  is  produced  when  the 
cervix  will  not  dilate  over  the  descending  head,  and  is  torn 
through  longitudinally,  the  rent  extending  upwards  into  the 
uterine  tissue. 

Grinding  or  crushing  is  found  at  that  part  of  the  uterus  which 
lies  in  contact  with  the  bony  prominences,  and  is  specially  prone 
to  occur  when  these  prominences  are  unduly  marked.  Openings 
made  in  this  way  have  jagged  edges,  much  bruised,  and  perhaps 
broken  into  shreds ;  their  direction  is  transverse  to  the  uterine 
axis.  Pevfovation  or  boring  through  at  a  point  of  the  uterus 
weakened  by  disease,  or  thinned  and  bruised  by  compression,  is 
practically  the  same  as  crushing. 

Complete  detachment  of  the  uterus  may  take  place  by  annular 
lacerations  through  the  cervix,  or  the  vagina  ;  and  the  organ 
may  be  bodily  torn  away  from  its  attachments,  after  delivery  by 
manual  force. 

SYMPTOMS    AND    DIAGNOSIS. 

Surgical  treatment  is  rarely  called  for  until  there  are 
symptoms  that  the  foetus  has  been  extruded  through  the  rent 
into  the  abdominal  cavity.  But  in  many  cases  it  is  possible  to 
diagnose  the  condition  with  a  fair  degree  of  certainty  before  this 
catastrophe  has  taken  place,  and  more  particularly  when  the 
foetus  has  only  partially  escaped. 

The  following  description  of  the  symptoms  of  rupture  is  from 
Barnes's  pen  :*  "  Sudden  acute  pain,  with  a  sense  of  rending  in 
the  belly,  sometimes  attended  with  an  audible  snap,  it  is  said  ; 
quick  collapse,  marked  by  pallor,  fainting,  extinction  of  pulse  ; 
vomiting;  some  hemorrhage  externally,  and  the  signs  of  ansemia 

*  Op.  Git.,  p.  342. 
21   * 


308  PUERPERAL   LAPAROTOMY. 

from  greater  loss  internally ;  cessation  of  uterine  contraction. 
If  the  child  be  thrust  wholly  or  partly  out  of  the  womb,  the 
abdomen  flattens  somewhat ;  there  is  retreat  of  the  presenting 
part  of  the  child  from  the  os  uteri ;  occasionally,  prolapse  of 
the  intestine  in  the  vagina,  or  beyond  the  vulva ;  great  pain, 
especially  on  palpation  of  the  abdomen,  where  irregular  hard 
projections  are  felt,  which  may  be  identified  as  parts  of  the 
foetus.  If  the  effusion  of  blood  be  great,  there  is  increased  and 
distressing  tension  of  the  abdominal  walls.  Cramp-like  or 
spasmodic  pains  follow.  The  flushed  face  becomes  suddenly 
deadly  pale  ;  the  eyes  lose  their  brilliancy ;  the  whole  surface 
is  covered  with  a  clammy  sweat ;  trembling  of  the  limbs  or 
repeated  faintings  announce  a  profuse  internal  haemorrhage. 
Presently,  when  reaction  comes,  the  patient  complains  of  feeling 
a  warm  fluid  pouring  out  in  the  neighbourhood  of  the  groins 
and  loins.  She  sometimes  feels  the  movements  of  the  child 
when  it  has  escaped  into  the  abdomen.  But  usually  the  child 
dies  quickly. 

"  It  has,  however,  often  been  observed  that  the  symptoms  are 
not  so  strongly  marked.  Sometimes  very  little  is  complained  of 
at  the  time  when  it  was  presumed  that  the  injury  took  place. 
The  collapse  creeps  on  gradually.  The  woman  may  be  even 
capable  of  walking  about  for  some  time.     .     .     . 

"  But,  sooner  or  later,  almost  always  within  two  or  three 
hours,  collapse  becomes  pronounced  and  pain  is  severe."  In 
such  case  we  may  infer  that  the  process  of  tearing  has  been 
gradual. 

In  many  cases  the  acute  symptoms  are  preceded  by  signs 
of  obstruction  to  delivery.  Boring  through  of  the  uterine  tissue 
may  be  going  on,  while  the  patient's  symptoms  are  simply  those 
of  exhaustion  or  irritation  under  long-continued  labour.  The 
completion  of  the  tearing  is  shown  by  the  onset  of  the  violent 
symptoms  just  described. 

When  the  foetus  has  been  extruded  into  the  abdominal 
cavity,  the  diagnosis  is  completed  by  passing  the  hand  into 
the  uterine  cavity,  and  detecting  the  rent.  Intestine  may  be 
felt  passing  into  the  uterine  cavity,  or  even  into  the  vagina. 


THE   OPERATION.  309 


OPERATIVE    TREATMENT    OF    RUPTURE    OF   THE    UTERUS. 

The  treatment  recommended  for  all  cases  is  abdominal 
section,  removal  of  the  foetus  and  its  membranes,  cleansing 
the  cavity,  and  either  suture  of  the  rent  or  removal  of  the 
uterus. 

Not  in  all  cases  will  it  be  advisable  to  suture  the  uterine 
tear.  The  wound  will  be,  in  all  probability,  an  irregular  one 
with  ragged  and  bruised  edges ;  it  will  usually  lie  low  down 
either  behind,  or  in  some  position  not  conveniently  situated  for 
suturing  ;  and,  most  important  of  all,  uterine  contractions  will 
probably  be  absent  or  very  feeble.  If  the  rare  combination  is 
met  with  of  a  moderately  clean  straight  wound,  a  convenient 
situation,  and  a  contracting  uterus,  simple  closure  of  the  wound 
may  be  had  recourse  to.  But  in  the  absence  of  this  combination, 
it  will  be  wise  to  finish  by  hysterectomy. 

The  operation  is  begun  exactly  as  for  Caesarean  section. 
The  child  and  placenta  are  extracted  ;  blood-clots  are  removed, 
and  the  abdomen  is  thoroughly  cleansed  by  irrigation  and  spong- 
ing. To  discover  the  rent,  it  may  be  necessary  to  turn  the 
uterus  out  of  the  wound.  Cases  are  recorded  where  recovery 
has  ensued  when  the  rent  has  been  left  unclosed.  But  the 
chances  of  success  are  greatest  with  a  perfectly  closed  uterine 
wound.  The  method  of  suturing  recommended  for  ordinary 
Caesarean  section  is  the  best.  If  the  edges  of  the  rent  are 
much  bruised  or  lacerated,  then  hysterectomy  is  recommended. 
Drainage  by  the  vagina,  if  the  opening  is  on  the  posterior 
surface,  may  be  used  with  advantage. 

The  per-centage  of  recoveries  after  this  operation  has  been 
variously  placed  at  68  (Jolly),  86  (Trask),  and,  in  the  United 
States,  at  53  (Harris).  It  is  certainl}'  more  favourable  than 
might  be  expected — perhaps,  than  it  ought  to  be.  The  worst 
cases  are  permitted  to  die :  if  more  cases  were  operated  on, 
more  lives  would  be  saved,  but  the  statistics  would  not  be 
so  favourable. 

Puerperal  hysterectomy  for  rupture  of  the  uterus  differs  in  no 


310  PUERPERAL  LAPARATOMY. 

important  particulars  from  the  operation  as  performed  for  other 
reasons.  The  incision  is  made  in  the  ordinary  way.  If  the 
ovum  is  intact,  an  attempt  may  be  made  to  remove  it  bodily ; 
but  this  cannot  often  succeed.  Much  time  may  be  saved  by 
removing  as  much  of  the  amniotic  fluid  as  possible  by  tapping 
before  removing  the  ovum  from  the  cavity.  In  every  case  the 
whole  ovum — membranes,  fcetus,  and  placenta — will  be  removed 
bodily,  and  as  far  as  possible  intact.  No  particle  of  tissue  is  to 
be  left  behind. 

If  the  foetus  alone  is  extruded,  and  the  placenta  and  mem- 
branes remain  inside  the  uterus,  the  foetus  is  removed,  and  the 
cord  divided  and  compressed  or  tied.  Then  the  collapsed  uterus 
is  turned  out  through  the  wound,  to  be  clamped  and  removed. 
If  the  foetus  is  only  partially  extruded,  it  is  quickly  pulled 
thorugh  the  rent ;  and  as  soon  as  it  is  removed  a  temporary 
constrictor  or  the  hand  is  passed  round  the  uterus,  as  low  down 
as  possible,  to  prevent  haemorrhage. 

The  uterus  being  turned  out  on  the  abdomen,  and  the 
situation  of  the  rupture  having  been  ascertained,  several  large 
sponges  are  packed  into  the  abdominal  cavity.  Before  putting 
on  the  clamp,  the  finger  should  be  passed  to  the  inside  of  the 
uterus,  to  make  sure  that  the  whole  of  the  torn  tissue,  inside  as 
well  as  outside,  is  above  the  level  fixed  for  applying  the  wire. 

The  pedicle  is  then  clamped,  fixed  in  the  wound,  and  treated 
exactly  as  in  Porro's  operation. 

Attention  is  now  paid  to  cleansing  of  the  abdomen,  which 
must  be  as  thorough  as  possible  consistently  with  rapidity.  The 
large  sponges,  soaked  with  blood  and  amniotic  fluid,  are  removed. 
The  cavity  is  thoroughly  washed  out  with  aseptic  fluid,  at  99° 
temperature,  by  means  of  an  irrigator  with  a  large  tube,  while 
the  intestines  are  freely  moved  about  by  the  fingers  inside  the 
cavity.  When  the  fluid  returns  clear,  fresh  sponges  are  placed 
in  the  pelvis  and  in  the  hollows  of  the  loins,  to  soak  up  what 
remains.  Too  much  time  must  not  be  wasted  in  endeavouring 
to  get  the  cavity  perfectly  dry. 

Drainage  will  be  called  for  in  a  proportion  of  cases  greater 
than  in  ordinary  Porro's  operations,  because  of  the  extravasation 


THE   OPERATION.  311 

before  operation.     Indeed,  the  insertion  of  a  drainage  tube  can 
scarcely  ever,  in  this  operation,  be  other  than  good  practice. 

The  further  procedures  as  regards  closure  of  wound, 
management  of  pedicle,  and  treatment  of  patient,  are  in  no 
way  different  from  those  described  under  the  head  of  Porro's 
operation. 


Operations  for  Ectopic  Gestation. 

Under  this  head  are  discussed  the  operative  proceedings 
which  may  be  employed  for  extra-uterine  pregnancy  properly  so 
called,  and  for  those  cases  of  misplaced  uterine  pregnancy  in 
which  spontaneous  delivery  cannot  take  place.  The  latter 
condition  has  its  type  in  cases  of  pregnancy  in  one  horn  of 
a  uterus  bicornis,  and  is  often,  from  its  most  marked  clinical 
feature,  spoken  of  as  "  missed  labour."  This  name  is,  how- 
ever, occasionally  applicable  to  all  forms  of  ectopic  gestation. 

History. — Heister,*  in  naming  the  indications  for  abdominal 
section,  places  first  this  one — "when  the  foetus  is  contained  in 
the  Fallopian  tube,  the  ovary,  or  the  cavity  of  the  abdomen." 
Simon,  t  in  his  elaborate  review  of  the  Caesarean  operation, 
speaks  of  abdominal  gestation  as  an  indication  for  operation. 
In  reviewing  the  history  of  actual  operations,  it  is  difficult  to 
decide  as  to  their  real  nature.  The  earliest  operations  were 
probably  performed  after  a  suppurating  sac  had  shown  signs  of 
bursting,  and  were  little  more  than  the  opening  of  an  abscess. 
Christopher  Bain's  case,  in  1540,  was  little  more  than  the 
opening  of  an  abscess.  The  well-known  cases  of  Noierus  in 
1 59 1,  and  of  Cyprian  in  1694,  were  almost  certainly  of  this 
nature.  The  first  genuine  laparotomy  for  extra-uterine  fcetation 
was  probably  that  of  Primerose  in  1594,  who  successfully  oper- 
ated on  Noierus's  patient  when  she  again  became  pregnant. 
Several  other  successes  were  about  this  time  reported  from  the 
Continent.  In  1764  Mr.  John  Bard,  a  New  York  surgeon,  first 
operated  in  America  ;  he  was  followed  by  Baynham,  Mc  Knight, 
Wishart,  Stevens,  and  others  (nearly  all  country  practitioners), 
and  a  considerable  number  of  successes  were  registered.  These 
operations  extend  to  about  1850,  the  beginning  of  the  era  of 
ovariotomy.  Up  to  the  end  of  1875,  Dr.  Parry,  for  his  classical 
work  on  Extra-uterine  Pregnancy,   had  collected    a    list   of   62 

*  Op.  cit.,  vol.  ii.,  p.  28.        t  Mem.  de  I'Acad,  de  Chirurg,  Paris,  vol.  ii. 


ANATOMY.  31S 

operations  for  the  removal  of  extra-uterine  children,  with  the 
encouraging  result  of  30  successes  and  32  failures. 

But  as  anatomical  and  clinical  knowledge  extended,  so  did 
the  sphere  of  operation.  For  rupture  of  the  sac  in  the  early- 
stages,  little  or  nothing  was  done  till  recent  times.  In  1849 
Dr.  Harbert,  an  American  surgeon,  first  suggested  operative 
treatment  for  this  terrible  accident ;  but  little  attention  was  paid 
to  his  proposal  till  1866  and  1867,  when  Dr.  Stephen  Rogers  of 
New  York  wrote  and  urged  operation.*  Moreau,!  curiously 
enough,  while  strongly  urging  abdominal  section  for  rupture  of 
the  sac  during  spurious  labour,  condemns  it  for  rupture  in  the 
early  stages.  The  operation  made  no  headway  till  Tait,  in 
recent  years,  took  it  up,  and,  by  a  remarkable  series  of  suc- 
cesses, placed  it  in  the  front  of  major  life-saving  operations. 
Up  to  Oct.  26th,  1887,1  Tait  had  operated  for  early  ruptured 
pregnancy  35  times,  with  2  deaths. 


PATHOLOGICAL    ANATOMY. 

The  actual  origin  of  extra-uterine  fcetation  ought  to  include 
a  consideration  of  its  causation.  Of  this  little  is  known.  Suffice 
it  to  say  that  it  specially  occurs  in  women  who  have  shown  an 
"inaptitude  for  conception,"  who  have  for  abnormally  long 
periods  been  sterile ;  and  in  women  who  have  some  malforma- 
tion of  the  uterus,  congenital  or  acquired.  More  definitel}'-, 
catarrh  of  the  Fallopian  tube  has  been  laid  down  as  a  cause. 
When  the  ciliated  epithelium  is  shed  in  any  part  of  the  tube, 
the  ovum  cannot  be  passed  along  it ;  it  rests  in  the  denuded 
space.  Here  the  spermatozoa,  endowed  with  independent 
powers  of  motion,  reach  it  and  impregnate  it ;  and  here  it 
develops.  Obstructive  catarrh  of  the  Fallopian  tube,  blocking 
the  canal  sufficiently  to  prevent  passage  of  the  large  ovum,  but 
not  enough  to  prevent  the  passage  of  the  small  spermatozoa ; 
adhesions  on  the  outside ;    simple  derangement  of  the  phj-sio- 

*  New  Yoi'h  Med,  Rec,  1867,  vol.  ii.,  p.  22. 

j  Traitt  Pratique  des  Accouchements,  ii.,  367;  Paris,  1841. 

J  Brit.  Med.  Journ.,  Nov.   12th,   1887. 


314  OPERATIONS  FOR  ECTOPIC   GESTATION. 

logical  functions  of  the  tube — spasm,  or  paralysis,  or  irregular 
action — have  all  been  assigned  as  causes. 

The  elaborate  classification  of  the  varieties  of  misplaced 
conception,  as  given  by  the  earlier  writers  (Dezemeris  gives  ten 
varieties),  has  now  been  reduced  to  one  or  two.  Parry  limits 
the  species  to  three — Tubal,  Ovarian,  and  Abdominal ;  these  he 
subdivides  into  eight  varieties.  The  simple  theory  of  Tait, 
held  by  Gaillard  Thomas  and  other  prominent  gynaecologists, 
explains  all  varieties.  He  holds  that  all  extra-uterine  con- 
ceptions are  at  first  tubal,  and  that  all  further  varieties  are  pro- 
duced after  rupture  of  the  primary  tubal  sac  and  escape  of  the 
ovum.  Interstitial  pregnancy  is  simply  a  variety  of  tubal,  where 
the  tube  enters  the  uterus ;  ovarian  pregnancy  is  tubal  among 
the  fimbriae.  If  the  rupture  takes  place  on  the  under  surface  of 
the  tube  where  it  is  embraced  by  the  broad  ligaments,  the  ovum 
may  develop  in  the  enclosed  cellular  tissue,  and  be  extra- 
peritoneal. If  the  rupture  takes  place  on  the  free  surface  of  the 
tube,  the  ovum  escapes  into  the  abdominal  cavity,  and  may 
develop  there. 

The  dismissal  of  ovarian  pregnancy  cannot,  however,  be 
made  in  a  word.  It  is  just  conceivable  that  the  ovum  may  not 
escape  from  a  ruptured  follicle,  and  that  spermatozoa  may  enter 
the  follicle  and  fertilise  it.  Putting  aside  the  older  cases,  we  can- 
not utterly  ignore  the  accurately  recorded  cases  of  Kammerer* 
and  Porter. f  Lusk,  Spiegelberg,  Werth,  and  other  competent 
modern  authorities  admit  the  validity  of  the  evidence  in  favour 
of  the  possibility  of  this  variety.  Most  cases  of  so-called  ovarian 
pregnancy  are  undoubtedly  instances  where  the  sac  has  de- 
veloped among  the  fimbriae  of  the  tube,  and  become  intimately 
adherent  to  the  ovary;  and  it  is  just  possible  that  all  are  to  be 
so  explained. 

Interstitial  pregnancy  is  simply  development  of  the  ovum  in 
that  part  of  the  tube  which  passes  into  the  uterine  cornu  ;  and 
not  in  the  uterine  tissue,  as  Breschet,  Meyer,  and  others, 
supposed. 

The  possibility  of  primary  abdominal  pregnancy  cannot  be 
*  Neiv  York  Med.  Journ.,  1865,  P-  i4i-     t  Ainei'.  Journ.  of  Med.  So.,  Jan.,  1853. 


ANATOMY.  315 

denied,  in  the  face  of  such  evidence  as  is  afforded  by  cases  of 
impregnation  through  abnormal  orifices  in  the  uterus.  Two 
such  are  recorded  b}^  Lecluj^se*  and  by  Koeberlef — one  through 
an  opening  unclosed  after  Caesarean  section,  the  other  through 
the  canal  left  after  hysterectomy  for  myoma.  Some  doubt  has 
recently  been  thrown  on  the  reality  of  Koeberle's  case.  A  case 
of  Kellar's  is  noted  by  Spiegelberg,  in  which  abdominal  preg- 
nancy occurred  two  years  after  an  almost  complete  hysterectomy. 
As  a  pathological  curiosity,  we  may  note  the  occurrence  of 
pregnancy  in  tubo-ovarian  cysts.  Paltauf|  has  minutely 
described  such  a  case ;  and  refers  to  two  other  similar  cases, 
though  with  some  doubt  as  to  their  reality. 

Practically,  we  may  admit  the  general,  if  not  the  absolute, 
truth  of  the  following  propositions : 

(i)  Every  extra-uterine  pregnancy  is  at  first  tubal.  Occur- 
ring where  the  tube  is  close  to  or  passing  through  the  uterine 
tissue,  it  may  be  called  Interstitial ;  where  it  is  broken  up  into 
fimbriae  at  the  infundibulum,  it  has  been  called  Tubo-ovarian  ; 
elsewhere  in  the  tube,  it  is  simply  named  Fallopian. 

(2)  When  rupture  of  the  sac  takes  place,  the  ovum  may 
escape  into  the  abdominal  cavity  or  into  the  cellular  tissue 
between  the  layers  of  the  broad  ligament.  The  former  is  known 
as  intra-peritoneal,  and  is  at  once  the  most  common  and  the 
most  dangerous ;  the  latter  is  less  dangerous,  naturally,  and 
more  easily  dealt  with  practically. 

The  state  of  parts  varies  according  to  the  duration  and 
position  and  behaviour  of  the  pregnancy. 

In  the  early  stages,  while  the  foetal  sac  lies  unruptured  in 

the  tube,  few  opportunities  of  examination  have  been  afforded. 

We  may  expect  to  find  increased  vascularity  of  the  tube  and  its 

annexa,  general  thickening  and  perhaps  tortuosity  of  the  whole 

duct,  with  a  boggy,  cystic,  and  vascular  tumour  in  one  part  of 

it.     In  the  described  cases,  the  mucous   membrane   has   been 

found  enormously  thickened ;  in  fact,  the  normal  decidua  would 

seem  to  have  formed  in  the  tube. 

*  Bull,  de  V  Acad,  de  MM.  de  Belgique,  1869. 

t  Related  by  Keller,  Des  Grossesses  Extra-utcrines,  Paris,  1872. 

J  Arch,  f,  Gyndk.,  1887,  xxx.,  iii.  ;  Lond.  Med.  Rec,  July  15th,  1887. 


316  OPERATIONS  FOR   ECTOPIC   GESTATION. 

After  rupture  of  the  sac  in  the  early  stages,  opportunities  of 
examination  are  far  too  frequent.  It  would  seem  that  rupture 
takes  place,  as  a  rule,  through  the  seat  of  the  placenta,  which 
might  be  expected  to  be  the  weakest  part.  In  such  cases  death 
is  usually  produced  by  haemorrhage,  which,  considering  the  size 
of  the  rent,  is  often  enormous  in  amount.  As  much  as  two 
gallons  of  blood  have  been  found  in  the  abdomen  after  death 
from  rupture,  and  two  or  three  pints  is  not  an  unusual  quantity. 
The  amount  of  blood  lost  has  no  relation  to  the  size  of  the  tear 
in  the  sac. 

The  ovum,  with  its  placenta,  may  escape  entire  through  the 
rent ;  or  the  ovum  and  its  membranes  may  escape,  while  the 
placenta  remains  attached ;  or  the  whole  ovum  may  remain 
undetached.  In  the  mass  of  blood-clot,  the  escaped  ovum  may 
easily  be  missed ;  in  most  cases,  even  if  the  foetus  cannot  be 
found,  the  placenta,  or  the  cord,  or  parts  of  the  membranes, 
are  found  in  or  near  the  tubal  sac. 

The  structure  of  the  walls  of  the  sac  will  depend  on  the 
position  of  the  ovum.  In  the  middle  of  the  tube,  they  will 
consist  simply  of  its  mucous,  muscular,  and  serous  la3^ers.  If 
the  sac  lies  in  the  uterine  portion  of  the  tube,  it  will  be  sur- 
rounded by  a  capsule  of  proper  uterine  muscle,  varying  in 
thickness  and  amount  according  to  the  depth  at  which  it  is 
placed.  At  the  fimbriated  extremity,  the  sac  may  be  only 
partially  covered  by  tubal  structure,  and  the  chorionic  villi  may 
protrude  into  the  abdominal  cavity.  There  is  no  true  decidua 
into  which  the  villi  of  the  chorion  are  inserted  ;  but  decidual 
membranes  are  formed  inside  the  uterus,  as  if  there  were  a 
normal    pregnancy. 

Kussmaul  holds  that  many  cases  of  so-called  tubal  fcetation 
are  really  instances  of  gestation  in  the  rudimentary  horn  of  a 
bicorned  uterus.  He  collected  thirteen  cases  of  this  sort,  all  of 
which  died  of  rupture  between  the  fourth  and  six  months. 
Parry  and  others  consider  that  Kussmaul  overestimates  the 
frequency  of  cornual  gestation ;  and  even  if  it  were  more  com- 
mon than  is  generally  supposed,  it  need  not  result  in  rupture. 
Missed  labour  is  a  more  frequent  result  of  such  pregnancies. 


ANATOMY.  317 

If  rupture  of  the  sac  do  not  prove  fatal  before  the  fourth 
month,  the  pregnancy  in  most  cases  goes  on  to  full  term.  If 
the  ovum  remains  in  the  tube,  the  tubal  walls  are  greatly 
thickened,  and  the  muscular  layers  much  hypertrophied.  This 
muscular  envelopment  is  much  greater  if  the  ovum  lies  partly 
inside  the  uterus.  In  some  cases  a  part  of  the  ovum  may  be 
within  the  uterine  cavity  :  thus,  the  placenta  has  been  found 
inside  the  uterus,  while  the  foetus  lay  in  the  tube ;  or  part  of  the 
child  may  be  intra-uterine  and  part  intra-tubal ;  or  the  placenta 
may  be  wholly  situated  in  the  tube,  while  the  child  is  inside  the 
uterus. 

Should  the  placenta,  after  rupture  of  the  cyst  and  escape  of 
the  foetus,  retain  its  attachment,  we  may  have  the  foetus  covered 
with  its  envelopes  developing  in  the  abdominal  cavity,  while  the 
placenta  in  the  tube  supplies  it  with  nourishment.  The  enve- 
lopes may  be  wanting,  and  the  foetus  is  then  surrounded  by  an 
adventitious  cyst  composed  of  organised  inflammatory  material. 
.  Should  the  placenta  be  extruded  with  the  foetus,  it  may  adhere 
to  any  contiguous  organ  :  omentum,  stomach,  large  and  small 
intestine,  abdominal  wall,  and  an  infinite  variety  of  combinations 
of  these,  have  been  found  serving  as  placental  sites.  The 
sigmoid  flexure  of  the  colon  is,  as  might  be  expected,  a  favourite 
situation.  In  a  general  way  we  may  expect  the  ovum  to  fall 
somewhere  into  Douglas's  pouch,  matting  together  whatever 
structures  may  be  encountered  there.  Thus  it  happens  that  the 
posterior  surface  of  the  uterus  is  frequently  involved.  As  the 
ovum  grows,  the  uterus  is  usually  elevated  and  pushed  forwards  ; 
it  is  always  enlarged,  generally  to  a  size  corresponding  to  the 
third  or  fourth  month  of  gestation,  and  may  or  may  not  contain 
decidua. 

As  regards  the  extra-peritoneal  variet}',  where  the  foetus 
grows  between  the  layers  of  the  broad  ligament,  a  most  im- 
portant study  has  recently  been  made  by  Berry  Hart  and  J.  T. 
Carter  of  Edinburgh,*  from  frozen  sections  of  two  specimens. 
One  of  the  specimens  was  a  four  and  half  months'  gestation 
in  situ  in  the  bony  pelvis  ;  the  other  an  entire  cadaver  with 
Edin.  Med.  Journ.,  Oct.  1887. 


318  OPERATIONS  FOR   ECTOPIC   GESTATION. 

advanced  abdominal  gestation.  The  latter  showed  a  Fallopian 
pregnancy  developing  to  an  extraordinary  extent  between  the 
layers  of  the  broad  ligament,  continuing  this  mode  of  growth 
till  it  had  stripped  off  the  peritoneum  from  the  uterus,  bladder, 
and  pelvic  floor,  until  it  became  in  great  part  surrounded  by 
a  peritoneal  capsule  derived  from  these  organs.  The  growth 
was,  in  fact,  entirely  extra-peritoneal ;  the  extra-peritoneal 
tissue,  with  its  blood-vessels,  was  practically  the  material  part  of 
the  placenta.  The  authors  hold  that  the  following  varieties  of 
extra  -  uterine  gestation,  or  rather  development,  have  been 
demonstrated  :  Tubal ;  Tubo-ovarian  ;  Sub-peritoneo-pelvic ; 
Sub-peritoneo-abdominal.  The  last  two  varieties  may  be  later 
developments  of  the  first. 

If  the  mother  survives  the  death  of  the  child  at  term,  certain 
changes  take  place  in  the  retained  foetus  which  vitally  influence 
the  progress  of  the  case.  In  the  first  place,  the  child  may  remain 
quiescent  in  its  envelope,  the  liquor  amnii  being  absorbed,  and 
the  cyst-wall  contracted  around  it.  Certain  atrophic  or  hetero- 
morphic  changes  may  now  take  place.  The  whole  ovum  may 
become  cartilaginous,  or  it  may  become  infiltrated  with  cal- 
careous matter  (when  it  is  known  as  a  lithopaedion) ;  or  it  may 
undergo  transformation  into  the  peculiar  material  known  as 
adipocere.  In  any  of  these  conditions  it  may  remain  for  long 
periods,  sometimes  for  many  years.  This  is  the  most  favourable 
termination. 

On  the  other  hand,  decomposition  may  take  place,  and  sup- 
puration is  set  up  in  the  sac.  Here  the  termination  is  the 
ordinary  one  for  all  abscesses — rupture.  The  rupture  rarely 
takes  place  into  the  abdominal  cavity  ;  but  usually,  after  for- 
mation of  adhesions,  into  one  or  other  of  the  contiguous  hollow 
viscera,  bowel  or  bladder,  or  through  the  abdominal  wall. 


SYMPTOMS    AND    DIAGNOSIS. 

Following  Parry,  we  may  best  study  the  symptoms  in  three 
stages  :  the  first,  up  to  the  period  of  probable  rupture  of  the  sac 
— that  is,  to  the  end  of  the  fourth  month;    the  second,  to  the 


SYMPTOMS.  319 

period  of  spurious  labour ;  the  third,  from  the  end  of  the  labour 
and  the  death  of  the  child  onwards. 

During  the  first  month  or  six  weeks  the  symptoms  may  be 
those  of  ordinary  pregnancy,  but  more  than  usually  variable 
and  indefinite.  At  the  end  of  this  time  signs,  often  urgent  and 
unmistakable,  appear  to  warn  the  patient  that  all  is  not  right. 
A  sudden  attack  of  violent  colicky  pain  in  the  hypogastrium, 
accompanied  by  profound  prostration  or  even  syncope,  is 
usually  the  first  sign  of  evil  import ;  this  may  last  for  a 
few  hours  or  even  days.  The  pain  disappears  as  suddenly  as 
it  came  on,  and  the  patient  regains  her  usual  health.  In  a 
few  days  or  weeks,  however,  similar  symptoms  recur,  and 
they  continue  intermittently  till  the  third  or  fourth  month. 

Such  attacks  usually  come  on  after  severe  exertion,  and  are 
probably  due  to  contractions  in  the  wall  of  the  sac,  or  to  its 
straining  against  over-distension.  Peritonitis  is  curiously  absent, 
as  proved  by  the  rapidity  with  which  recovery  takes  place. 

During  this  stage  a  frequent  occurrence  is  the  discharge  of 
dark  clotted  blood  from  the  uterus.  This  takes  place  at  irreg- 
ular intervals,  lasts  for  uncertain  periods,  and  disappears  as 
capriciously  as  it  comes.  Sometimes  pieces  of  the  decidua  are 
found  in  the  discharge. 

A  vaginal  examination  at  this  period  reveals  some  enlarge- 
ment of  the  uterus,  with  displacement,  usually  forwards,  and 
great  tenderness  in  the  pelvis.  The  enlargement  is  not  so  great 
as  we  should  expect  in  a  normal  gestation  of  the  same  standing  ; 
but  this  sign  is  not  trustworthy,  because  it  is  so  difficult  to 
decide  as  to  the  duration  of  extra-uterine  pregnancy.  In  the 
region  of  the  greatest  tenderness,  usually  behind  the  uterus, 
we  may  expect  to  find  the  tumour.  To  make  a  satisfac- 
tory examination,  an  anaesthetic  is  usually  necessary.  A 
rounded,  soft,  boggy  or  fluctuating  mass,  of  size  corre- 
sponding to  the  period  of  gestation,  is  usually  all  tliat  can  be 
made  out.  In  this  stage  the  sign  of  ballottement  cannot  be 
elicited. 

When  quickening  has  taken  place,  the  symptoms  undergo  a 
marked  change.     The  attacks  of  colic  diminish  or  disappear. 


320  OPERATIONS  FOR   ECTOPIC   GESTATION. 

Metrorrhagia  either  disappears  or  becomes  unimportant.  Foetal 
movements  are  now  detected,  often  exaggerated  and  usually  on 
one  side.  The  abdomen  perceptibly  enlarges,  more  on  one  side 
than  the  other.  The  uterine  displacement  becomes  more  marked, 
and  is  attended  with  elevation  and  fixation.  Often  the  fundus 
uteri  can  be  felt  through  the  abdominal  wall,  over  the  pubes 
and  to  one  side. 

Through  the  vagina  the  tumour  will  now  readily  be  felt, 
rounded,  fluctuating,  and  containing  a  hard  body  in  the  midst 
of  its  fluid.  Frequently  the  cyst-wall  is  so  thin  that  the  out- 
lines of  the  foetus  can  be  made  out  with  great  accuracy.  Pass- 
ing the  catheter,  by  telling  the  position  of  the  bladder,  may  be 
of  assistance :  the  uterine  sound  is  not  to  be  used,  except  in 
cases  of  urgency.  Symptoms  of  irritation  of  the  bladder  are 
frequently  present.  Irritation  of  the  rectum  is  more  common, 
because  the  sac  is  often  adherent  to  its  walls ;  physical  obstruc- 
tion to  the  passage  of  faeces  may  be  caused  by  the  bulk  of  the 
tumour. 

The  end  of  this  period  is  signalised,  at  the  full  term,  by  a 
spurious  labour.  The  pains  are  almost  identical  with  those 
characteristic  of  the  first  stage  of  normal  parturition,  and  may 
deceive  physician  as  well  as  patient.  They  differ  from  those  of 
natural  labour  in  that  they  do  not  steadily  increase  in  severity, 
but  have  irregular  aggravations,  with  remissions  and  inter- 
missions. Finally  they  pass  off  altogether,  after  continuing  over 
many  hours  or  even  days. 

Concomitantly  with  the  fruitless  labour  there  goes  on  a  dis- 
charge of  blood  from  the  vagina.  If  the  decidual  membranes 
have  not  previously  been  expelled,  they  are  expelled  now. 
When  the  sanguineous  discharge  ceases,  another  comes  on  which 
is  analogous  to  the  lochia. 

It  would  seem  that  the  uterus  is  mainly  to  be  credited  with 
the  causation  of  these  pains.  Only  tubal  sacs  have  muscular 
fibres  ;  but  labour  comes  on  all  the  same  if  the  gestation  is 
ventral.  Mr.  Scott,*'  during  laparotomy  in  a  case,  found  the 
uterus  contracting  strongly  and  regularly,  as  in  normal  labour. 
Lond,  Obsiet.  Soc.  Trans.,  1873,  vol.   xiv. ,  p.   370. 


SYMPTOMS.  321 

The  false  labour  also  seems  to  have  little  influence  on  the  sac ; 
at  least,  it  rarely  ruptures  or  becomes  inflamed.  A  few  cases  of 
rupture,  with  escape  of  the  child  into  abdomen,  rectum,  or 
vagina,  are  recorded. 

A  curious  sequence  to  this  labour  is  death  of  the  child.  Just 
before  it  dies  it  frequently  struggles  violently  for  some  time, 
causing  great  distress  to  the  mother.  When  the  child  dies  the 
abdomen  diminishes  in  size,  from  absorption  of  the  amniotic  fluid. 
If  the  child  is  to  remain  quiescent,  or  undergoes  atrophic 
changes,  the  diminution  remains,  and  becomes  more  marked ;  if 
decomposition  takes  place,  the  sac  refills,  and  its  distension  is 
accompanied  with  signs  of  internal  suppuration,  often  of  a  very 
acute  nature.  Special  symptoms  may  be  referred  to  special 
organs  through  which  the  abscess  is  preparing  to  discharge  its 
contents.  In  the  rectum,  tenesmus,  with  a  feeling  of  weight 
and  diarrhoea  ;  in  the  bladder,  irritability,  with  frequent 
micturition  and  signs  of  catarrh;  in  the  vagina,  fulness,  pain^ 
heat,  and  a  leucorrhceal  discharge,  indicate  the  site  of  election 
for  bursting.  One  case,  at  least,  has  burst  into  the  stomach. 
Sometimes  the  opening  is  double — as,  for  instance,  through 
rectum  and  abdominal  wall. 

Signs  of  Rupture  of  the  Cyst. — In  about  one-half  of  the  cases 
rupture  of  the  sac  takes  place  before  completion  of  the  full 
term.  This  is  attended  with  symptoms  of  a  most  serious  and 
alarming  nature.  Premonitory  attacks  of  griping  pain  in  the 
lower  abdomen  are  followed  b}^  a  sudden  seizure  of  agonising 
pain,  often  with  a  sense  as  of  something  having  given  way  ;  and 
this  is  rapidly  followed  by  prostration  and  collapse.  During 
this  period  of  "abdominal  collapse"  one  fainting  fit  follows 
another ;  and  the  patient  either  dies  very  soon,  or  slowly  rallies 
to  an  attack  of  peritonitis.  Frequently,  considerable  quantities 
of  blood  are  effused  ;  in  these  cases,  the  peritonitis  is  late  in 
coming  on,  and  is  not  very  acute. 

The  special  symptoms  of  pregnane}^  in  a  hernial  sac,  and  of 
twin  foetation — one  inside  the  uterus  and  one  outside,  or  both 
outside, — being  simply  cumulative  of  individual  symptoms,  need 
not  be  discussed. 

22 


322  OPERATIONS  FOR   ECTOPIC   GESTATION. 


INDICATIONS    TO     OPERATE. 

Extra-uterine  pregnancy  may  be  regarded  as  among  the 
most  deadly  of  diseases.  Nearly  three-fourths  of  all  cases 
die ;  and  more  than  one  half  of  these  deaths  is  from  rup- 
-ture  of  the  cyst.  Parry  writes :  "  Recovery  is  so  rare  after 
rupture,  that  the  physician  has  no  right  to  allow  the  fact 
that  it  may  occur  to  influence  him  in  deciding  upon  a  plan  of 
treatment." 

For  such  a  disease,  therefore,  no  half-hearted  or  tentative 
measures  are  to  be  tolerated.  In  some  of  its  aspects  it  is  as 
dangerous  as  haemorrhage  from  an  artery  of  the  second  magni- 
tude ;  in  others,  it  may  rank  with  strangulated  hernia  ;  while 
under  its  most  favourable  conditions,  it  is  fraught  with  an 
insecurity  which  at  any  moment  may  develop  into  acute 
danger. 

Parry's  statistics  of  500  cases  of  extra-uterine  foetation 
give  a  mortality  of  67.2  per  cent.     In  336  cases  the  causes  of 


death  were  mentioned.     The  most 

Rupture  of  Sac 

Exhaustion       

Peritonitis         

Pregnancy        ...     ... 

Intestinal  obstruction 


important  are : 

...        174 

54 
24 

16 


To  these  Lusk**  has  added  103  cases,  occurring  between 
1875  and  1886,  excluding  cases  of  rupture  in  the  early  stages. 
Of  29  cases  of  abdominal  pregnancy  terminating  in  fistulous 
openings,  9  died.  These,  it  must  be  remembered,  are  often 
regarded  as  examples  of  spontaneous  cure  ;  and  if  to  the  actual 
high  mortality  is  added  the  probable  continued  impairment  of 
health  or  comfort,  it  will  be  evident  that  spontaneous  discharge 
of  the  foetus  is  not  a  termination  to  be  hopefully  anticipated. 
Eight  cases  died  before  fistula  had  formed,  at  periods  varying 
from  8  months  to  i|-  year.  Of  52  cases  of  laparotomy  per- 
formed at  varying  periods  after  death  of  the  fcetus,  37  recovered 
*  Brit.   Med.  Joiirn.,  Dec.  4th,  18S6. 


EVACUATION   OF  LIQUOR   AMNII.  323 

and  15  died.  Of  the  fatal  cases,  only  three — all  cases  of  free 
haemorrhage — could  be  attributed  to  the  operation.  In  all  the 
others,  the  cases  were  almost  hopeless  at  the  time  of  operation  ; 
as  Lusk  remarks,  "the  resources  of  surgery  are  rarely  successful 
when  practiced  on  the  dying," 

Harris  of  Philadelphia  has  investigated  the  mortality  of 
primary  laparotomy  in  cases  of  extra-uterine  pregnancy. 
Primary  operations  he  reckons  as  those  performed,  not  only 
while  the  foetus  is  living,  but  after  it  has  reached  a  viable  period 
of  gestation — thus  adopting  the  ordinarily  accepted  meaning 
of  the  term  "primary."  Of  25  cases  collected,  23  mothers  died 
and  18  children:  12  mothers  died  of  haemorrhage;  and  this 
haemorrhage  may  occur  during  the  separation  of  the  placenta,  as 
late  as  a  fortnight  after,  as  in  Joseph  Price's  case.  It  is  clear 
that  if  this  class  of  operation  is  to  be  performed,  some  extra- 
ordinary means  of  controlling  haemorrhage  must  be  adopted. 
Harris*  recommends  ligature  of  the  vessels  supplying  the 
placenta,  and  its  removal  with  the  cyst  if  possible :  if  this  is 
impossible,  he  recommends  careful  antiseptic  treatment  of  the 
placenta,   to  prevent  its  decomposition. 

Before  setting  down  the  indications  for  the  major  operation, 
it  will  be  necessary  shortly  to  estimate  the  value  of  certain 
minor  proceedings. 

Evacuation  of  the  Liquor  Amnii. — Sir  James  Simpson,!  in 
1864,  treated  a  case  by  puncturing  the  cyst  through  the  vagina. 
The  child  was  not  killed,  and  the  mother  died  in  three  days. 
Braxton  Hicks,.|  in  1865,  by  a  similar  method  succeeded  in 
killing  the  child,  but  the  mother  died  of  haemorrhage.  Two 
years  later,  and  quite  independently,  Greenhalgh§  was  able  to 
record  a  success.  Dr.  James  of  Philadelphia  in  1867  had  a 
success,  which  was  near  being  a  failure.  A  few  successes  and 
more  failures  have  since  then  been  recorded,  and  the  plan  has 
now  been  practically  abandoned. 

*  Annals  0/ Sui'geyy,  ]u\y,  1887.      f  Ed.  Med.  Journ.,  March,  1864,  p.  S65. 

\  Lond.  Obstet.  Soc.  Trans.,  1866,  vol.  vii.,  p.  95. 

§  Lancet,  March  23rd,  1867. 

22   * 


324  OPERATIONS  FOR   ECTOPIC  GESTATION. 

Injection  of  Lethal  Substances  into  the  Fcetus  and  surrotcnding 
Fluids. — Joulin,  in  1863,  is  credited  with  the  invention  of  this 
plan;  but  Friedrich,  in  1864,  was  the  first  to  put  it  into 
practice.  Morphia  was  used,  and  the  case  was  successful : 
but  it  is  doubtful  if  it  was  one  of  ectopic  gestation  at  all. 
Koeberle  followed  with  a  success,  and  others  are  recorded. 
Matthews  Duncan  has  combined  the  plan  with  electricity  ;  but, 
in  spite  of  most  persevering,  skilful,  and  painstaking  efforts, 
without  success.  At  best  this  plan  is  uncertain,  and  it  is 
dangerous. 

Elytrotomy. — A  good  many  cases  have  been  recorded  of  opera- 
tion by  the  vagina.  Parry  records  15  such  operations,  with  six 
recoveries.  King  of  Georgia,  in  1817,  was  probably  the  first  to 
remove  an  extra-uterine  foetus  by  vaginal  incision.  Bandl,  in 
1874,  operated  in  the  same  way,  but  without  success.  Gaillard 
Thomas  used  the  galvano-cautery  for  division  of  the  tissues, 
and  the  patient  narrowly  escaped  with  her  life.  Herman* 
collected  33  cases  of  operation  by  vagina,  and  from  his  consider- 
ation of  these  drew  certain  conclusions  which  are  worthy  of 
being  quoted:  i.  The  operation  of  opening  an  extra-uterine 
gestation  sac  by  the  vagina  early  in  pregnancy,  before  rupture 
has  taken  place,  by  the  cautery  knife  or  otherwise,  is  a  dangerous 
and  unscientific  proceeding.  Abdominal  section  ought  always 
to  be  preferred  to  this.  2.  Soon  after  rupture  has  taken  place, 
when  interference  is  called  for  to  arrest  haemorrhage,  abdominal 
section  is  more  likel}^  to  succeed  than  vaginal.  3.  When  rupture 
has  taken  place,  and  the  effusion  of  blood  is  followed  by  pyrexia, 
the  indications  for  incision  of  the  vagina  are  the  same  as  those 
in  haematocele  from  any  other  cause.  4.  At,  or  soon  after  full 
term,  before  suppuration  has  taken  place,  there  might  be  con- 
ditions which  indicate  delivery  by  the  vagina  as  preferable  to 
abdominal  section.  These  are :  {a)  When  the  foetus  is  pre- 
senting with  the  head,  breech,  or  feet,  so  that  it  can  be  extracted 
without  altering  its  position  ;  [b)  when  it  is  quite  certain,  from 
the  thinness  of  the  structures  separating  the  presenting  part 
from  the  vaginal  canal,  that  the  placenta  is  not  implanted  on 
*  Brit.  Med.  Journ.,  Dec.  3rd,  1887. 


THE  ELECTRIC   CURRENT.  325 

this  part  of  the  sac,  and  it  is  not  certain  that  the  placenta  is  not 
implanted  on  the  anterior  abdominal  wall.  5.  If  the  child  can- 
not be  delivered  by  the  vagina  without  being  turned,  abdominal 
section  should  be  performed.  6.  No  attempt  should  be  made  to 
remove  the  placenta ;  the  sac  should  frequently  be  washed  out. 

Broadly  speaking,  vaginal  section  may  properly  be  performed 
under  the  above  conditions  when  the  state  of  parts — a  thin  sac 
and  a  presenting  foetus — invites  the  proceeding;  or  when  nature 
is  showing  a  disposition  to  make  an  opening  through  the 
vagina. 

Robertson*  of  Oldham  has  successfully  operated  by  dividing 
the  perineum,  and  separating  the  walls  of  the  vagina  and 
rectum. 

The  Application  of  the  Electric  Current. — Voillemier  is  said  to 
have  first  suggested  electricity ;  Cazeaux,  after  him,  certainly 
did  so.  Bachetti  of  Pisa,  in  1853,  was  the  first  actually  to 
use  electricity  to  kill  the  foetus,  and  he  was  successful.  Braxton 
Hicks  in  1 866,1  Allen  of  Philadelphia,!  and  others,  by  various 
methods  of  discharge,  sought  the  same  end.  Gaillard  Thomas, 
in  particular,  has  paid  much  attention  to  this  plan  of  killing  the 
ovum,  and  has  done  much  to  improve  and  to  simplify  its  appli- 
cation. He  records  several  striking  cases  of  success.  Dr. 
Blackwood  of  Philadelphia, §  who  has  paid  a  good  deal  of 
attention  to  this  subject,  strongly  recommends  Faradism, 
because  it  is  controllable  and  acts  with  greater  energy  on 
the  embryo.  Believing  that  it  acts  by  "  tetanization  "  of  the 
whole  mass  of  the  embryo,  he  would  give  the  maximum  dose 
at  one  sitting,  prolonged  for  an  hour  or  more.  Galvano- 
puncture  he  considers  waste  of  time.  As  now  employed, 
electricity  is  usually  applied  by  means  of  an  induction 
apparatus ;  one  electrode  being  placed  on  the  most  pro- 
minent part  of  the  swelling  in  the  vagina,  and  the  other 
on  the  opposite  side  of  the  tumour  over  the  parietes.  Several 
appliances  are  usually  necessary. 

*  Brit.  Med.  Journ.,  Feb.  13th,  1886. 

t  Loud.  Obstet.  Soc.  Trans.,  vol.  vii.,  p.  96.     \  Amer.  Journ.  Obstct.,  May,  1872. 

§  Phila.  Med.  and  Surg.  Rep.,  Sept.  3rd,  1887. 


326  OPERATIONS  FOR   ECTOPIC   GESTATION. 

Brothers*  has  collected  43  cases  treated  by  electricity  with 
two  deaths.  In  four  cases  there  were  alarming  symptoms,  but  the 
patients  recovered.  In  two  cases  the  fcetus  was  not  killed ;  and 
in  two  suppuration  of  the  sac  with  septicaemia  occurred,  the 
patients  recovering  after  discharge  of  the  fcetus,  in  each  case 
through  the  vagina.  In  three  of  the  cases  contractions  of  the 
muscular  layer  of  the  Fallopian  tube  is  said  to  have  resulted  in 
expulsion  of  the  fcetus  into  the  vagina.  In  some  of  the  cases 
more  accurate  records  might  strengthen  a  belief  in  their  authen- 
ticity ;  and  among  those  that  are  well  recorded,  serious  doubts 
must  arise  in  the  mind  of  the  critic  as  to  the  validity  of  the 
diagnosis  in  several. 

The  position  that  electricit}'  at  present  holds  as  a  plan  of 
treatment  in  extra-uterine  fcetation  is,  that  it  is  suitable  only 
in  the  early  stages,  where  it  is  not  very  dangerous  and  is  followed 
by  an  encouraging  degree  of  success.  It  must  be  noted,  that  in 
these  early  stages  diagnosis  is  uncertain  ;  that  the  stimulation 
of  an  electric  discharge  may  induce  rupture ;  and  that  danger 
is  not  over  when  the  foetus  is  killed.  It  may  not  destroy  the 
vitality  of  the  placenta.  Leopold's  experimentsf  with  the 
fcetus  in  pregnant  rabbits  would  seem  to  show  that  the  presence 
of  a  dead  embryo  in  the  abdominal  cavity  is  a  condition  by  no 
means  free  from  danger;  and  actual  results  in  the  human  female 
show  the  same  thing. 

Electricity  is  the  best  of  all  minor  plans  of  operation ;  but 
it  is  not  quite  free  from  danger,  it  is  not  always  successful,  and 
in  its  limited  application  it  enters  into  competition  with  lapar- 
otomy in  the  same  field  where  laparotomy  is  most  successful 
in  primary  results,  and  has  also  secondary  results  which  are 
absolutely  perfect. 

A  dispassionate  consideration  of  the  natural  terminations  of 
the  disease,  and  of  the  effects  of  minor  modes  of  treatment, 
almost  drives  one  to  the  conclusion  that,  at  all  stages  and  under 
all  circumstances  (excluding  the  exceptional  cases  wherein  ely- 
trotomy  is  permissible),  abdominal  section  is  the  best  treatment. 

*  Amer.  Journ.  of  Obstet.,  xxi.,  May,  1888. 
t  Archiv.  fur  Gyn.  and  Med.  Times  and  Gaz.,  1S82,  vol.  i.,  p.  41. 


ABDOMINAL   SECTION.  327 

In  the  early  stages  and  before  rupture,  abdominal  section  ought 
to  be  a  very  simple  and  successful  proceeding.  Veit,  according 
to  Harris,*  has  had  seven  operations,  all  successful.  This  has 
been  called  the  "primitive"  operation.  Even  during  the 
alarming  state  produced  by  rupture,  one  surgeon  (Tait)  can 
show  a  record  of  35  operations  with  two  deaths.  Between  the 
fourth  and  ninth  months  the  dangers  to  the  patient  are  least : 
the  next  period  of  danger  comes  on  at  term.  But  if  the  risk 
to  the  patient  during  those  five  months  is  stationary,  tli^  danger 
of  operation  is  weekly  added  to.  The  size  of  the  foetus  increases 
the  magnitude  of  the  operation  :  if,  as  is  likely,  operation  will 
be  called  for  at  the  end  of  nine  months,  why  wait  for  that  time, 
when  the  dangers  are  so  much  greater  ?  As  a  result  of  oper- 
ation, a  living  mother  and  a  living  child  can  be  credited  only  to 
five  surgeons — Jessop  of  Leeds,  A.  Martin  of  Berlin,  Eastman 
of  Philadelphia,  t  Breisky,  I  and  Lawson  Tait.  The  wise 
practice  is,  that  the  less  important  life  shall  give  way  to  the 
more  important ;  that  where  sacrifice  is  called  for,  the  child 
must  give  way  to  the  mother.  It  happens  that  the  period 
which  is  least  dangerous  to  the  mother  is  most  dangerous  for 
operation — speaking  of  the  whole  period  as  one.  But  there  is 
great  difference  in  risk  between  an  operation  performed  in  the 
fifth  month,  and  one  in  the  ninth.  To  the  latter  operation, 
where  the  child  is  living  and  viable,  the  name  "  Primary"  has 
been  given;  the  operation  after  full  term,  when  the  child  is 
dead,  has  been  called  "Secondary."  This  nomenclature  is 
misleading. 

A  Primary  operation  is  performed  at  the  worst  possible 
period,  as  regards  the  safety  of  the  mother.  The  results,  so 
far,  have  been  31  operations  with  25  deaths.  Of  the  children, 
16  lived  ;  but  the  mortality  among  them  during  the  first  few 
months  has  been,  as  might  be  expected,  high.  In  only  five  cases 
were  both  mother  and  child  saved, §  Indeed,  if  the  child  is 
viable,  or  even  if  the  case  has  passed  the  sixth  month,  it  is 

*  Amey.  Journ.  Med,.  Sc,  Sept,  1888. 

t  Amer.  Joiirn.  Obstet.,  Oct.,  1888.  J   Wien.  Med.  Presse,  xlviii.,  1887. 

§  Harris,  Amey.  Journ.  Med.  Sc,  Sept.,  i888. 


328  OPERATIONS  FOR   ECTOPIC   GESTATION. 

very  doubtful  whether  it  would  not  be  botter  practice  to  wait 
till  the  period  of  false  labour  has  passed  by,  and  operate  when 
the  child  is  dead  and  the  placental  circulation  has  ceased.  Of 
course,  the  case  must  be  carefully  watched,  and  any  indication 
of  change  promptly  met. 

I  would  summarise  the  indications  for  operation  by  abdom- 
inal section,  in  extra-uterine  foetation,  as  follows  : 

I.  In  all  cases  before  the  period  of  expected  tubal  rupture 
(25-  to  3|-  months),  in  fact,  as  soon  as  the  condition  has  been 
discovered,  should  electricity  fail  to  kill  the  ovum. 

II.  In  all  cases  of  tubal  rupture,  as  soon  as  possible  after 
the  condition  has  been  diagnosed. 

III.  In  all  cases  up  to  the  fourth  month  in  which  the  foetus 
continues  to  live.  Between  the  fourth  month  and  the  period  of 
false  labour,  operation  is  not  advisable. 

IV.  In  all  cases  after  false  labour  when  the  child  is  dead 
and  the  amnion  absorbed.  If  suppuration  takes  place,  operation 
is  imperative  ;  if  the  foetus  is  quiescent,  operation,  though 
advisable  in  the  view  of  preventing  further  trouble,  is  not 
urgent.  Absorption  of  amnion  is  waited  for,  because  this 
indicates  cessation  of  circulation  in  the  placenta. 

V.  In  all  cases  where  the  condition  endangers  the  life  of  the 
mother. 

Speaking  broadly,  operation  ought  not  to  be  left  as  a  last 
resort :  it  ought  to  be  ranked  as  a  mode  of  treatment.  The 
natural  course  of  the  gestation  being  intelligently  foreseen,  the 
best  treatment  ought  to  be  available  at  all  times,  and  not  only 
when  a  catastrophe  has  taken  place.  The  following  case*' 
points  its  own  moral :  "  In  October,  1875,  three  prominent 
Philadelphia  obstetricians  met  daily  in  consultation  for  sixteen 
days  over  the  case  of  a  lady  who  was  suffering  the  pains  of 
false  labour.  ...  As  they  could  not  promise  the  husband 
that  an  operation  would  probably  save  the  life  of  his  wife,  they 
waited  for  the  time  to  come  when  they  could  do  this ;  but, 
while  doing  so,  and  when  the  lady  appeared  to  be  getting 
better,  she  was  suddenly  seized  with  agonising  pains,  followed 
at  once  by  a  state  of  collapse,  and  died  in  thirty  minutes." 
*  Harris,  Intevnat,  Cyclop.  Surg.,  vol,  vi.,  p.  784. 


OPERATIVE  METHODS.  329 


THE    OPERATION. 

Laparotomy  for  ectopic  gestation  may  be  conveniently 
described  as  five  varieties  of  procedure  : 

I.  Removal  of  the  sac  in  the  early  months. 
II.  Operation    on    account  of  haemorrhage    from    tubal 
rupture. 
III.  Operation  while  the  child  is  alive,  between  the  fourth 

month  and  the  full  term. 
IV.  Operation  for  rupture  of  the  sac  after  false  labour. 
V.  Operation  with  a  dead  or  decomposing  foetus. 

Removal  of  the  Sac  before  the  Fourth  Month. — This  operation — 
"  Laparo-cystectomy,"  as  it  has  been  called — is  of  the  simplest 
possible  nature.  It  is  essentially  half  the  operation  of  Removal 
of  the  Uterine  Appendages — or  even  less  than  this,  for  the 
ovary  need  not  necessarily  be  removed. 

The  abdomen  being  opened,  the  situation  and  connections  of 
the  cyst  are  made  out  by  two  fingers  passed  into  the  cavity. 
The  tumour  is  gently,  and  without  unduly  compressing  it,  drawn 
to  the  surface.  A  suitable  site  for  a  pedicle  is  selected,  with  or 
without  the  ovary  included,  according  to  the  situation  of  that 
organ ;  ligatures  are  placed  around  it,  and  the  tumour  is  cut 
away.  In  most  cases  the  Staffordshire  knot  will  be  found  per- 
fectly efficient.  If  the  pedicle  is  very  broad,  two  Staffordshire 
knots,  or  a  chain  ligature,  may  be  substituted. 

Operation  for  Hismorrhage  from  Rupture  of  Tubal  Gestation. — The 
primary  object  of  operation  here  is,  to  check  haemorrhage :  with 
this  we  associate  removal  of  extravasated  blood  from  the  ab- 
dominal cavity,  extraction  of  the  ovum,  and  also  removal  of  the 
gestation-sac.  The  operation  is  performed  while  the  patient  is 
suffering  from  acute  anaemia,  possibly  from  profound  collapse. 

When  the  abdomen  is  opened,  there  will  probably  be  an 
escape  of  blood,  and  the  pelvis  will  be  found  more  or  less  com- 
pletely filled  with  blood-clot.     Through  the  clot  the  fingers  are 


330  OPERATIONS  FOR   ECTOPIC   GESTATION. 

pushed  to  the  fundus  uteri,  and  passed  along  each  broad  liga- 
ment embracing  the  Fallopian  tubes.  The  site  of  gestation  will 
be  made  out  as  a  soft  boggy  enlargement  of  varying  size  and 
consistency,  according  as  the  ovum  remains  in  situ  or  not.  This 
is  brought  to  the  surface,  and  examined  for  a  rent.  A  pedicle 
is  fixed  upon,  ligatures  are  placed  and  tied  in  a  suitable  manner, 
and  the  whole  sac  is  cut  away.  It  is  a  better  as  well  as  a 
speedier  plan  to  cut  away  the  whole  sac,  than  to  endeavour  to 
stem  bleeding  from  the  rent.  Rarely  does  the  complete  ovum 
remain  in  the  sac.  Sometimes  the  placenta  is  found,  while  the 
foetus  has  escaped  ;  and  frequently  the  entire  ovum  is  extruded, 
and  lies  amidst  the  blood-clots. 

The  extravasated  blood  is  removed,  at  first,  by  the  fingers  or 
hand;  then,  by  irrigation  with  a  hot  aseptic  fluid;  and  finally, 
by  sponging.  These  manipulations  may  demand  prolongation 
of  the  parietal  incision.  When  the  cavity  is  dry,  the  wound  is 
closed  in  the  ordinary  manner. 

In  many  cases  the  indication  to  operate  is  simply  an  alarm- 
ing pelvic  haemorrhage,  and  the  diagnosis  is  frequently  made 
only  after  operation.  This  is  of  no  consequence  in  respect  of 
treatment.  The  first  indication  of  extra-uterine  pregnancy  may 
be  this  alarming  haemorrhage,  following  rupture  of  the  sac  :  an 
intra-peritoneal  haemorrhage  is  most  frequently  of  this  nature, 
and  we  must  promptly  act  on  this  presumption.  No  patient 
should  be  permitted  to  die  while  we  wait  for  the  evolution  of 
diagnostic  signs. 

Operation  between  the  Fourth  Month  and  the  full  Term,  while  the 
Child  is  Alive. — Although  the  operative  details  are  essentially  the 
same  between  the  end  of  the  fourth  and  the  end  of  the  ninth 
month,  the  operative  results,  so  far  as  the  mother  is  concerned, 
are  very  different.  Apart  from  the  shock  of  the  operation,  which 
is  naturally  greater  after  removal  of  a  large  foetus  than  of  a  small 
one,  the  chief  danger — haemorrhage — is  increased  with  the  age, 
and  consequently  the  size,  of  the  placenta.  As  already  re- 
marked, the  primary  operation,  so  called,  for  delivery  of  a  viable 
foetus  is  not  to  be  recommended,  unless  urgent  symptoms  on  the 


OPERATION    WITH   CHILD  ALIVE.  331 

mother's  part  call  for  it.  And,  generally  speaking,  the  condition 
of  the  mother,  before  the  child  is  viable,  is  the  call  to  operate. 
Diarrhoea  ;  rectal  or  vesical  tenesmus,  irritation  or  inflammation  ; 
repeated  attacks  of  pain ;  increasing  weakness  and  such  symp- 
toms, will  usually  be  present  in  patients  submitted  to  the 
operation  here  described. 

The  leading  features  of  the  operation  are :  incision  of  the 
sac  (if  there  is  one),  removal  of  the  foetus,  cleansing  the  cavity 
of  the  sac,  stitching  its  edges  to  the  abdominal  opening,  and 
leaving  the  placenta  to  be  separated  b}'  natural  processes.  But 
an  endless  variety  in  detail  may  be  expected,  demanding  the 
exhibition  of  skill,  dexterity,  and  tact  on  the  part  of  the 
surgeon. 

Thus,  intestine  may  be  found  closely  adherent  to  the  sac  at 
the  site  where  it  is  most  desirable  to  lay  it  open.  Or,  the 
placenta  may  be  placed  so  that  it  is  impossible  to  enter  the  sac 
from  the  front  without  passing  through  its  substance.  The 
surgeon  must  do  his  best  to  aim  at  a  minimum  of  traumatic 
disturbance,  with  efficient  technical  completion  of  the  steps  of 
the  operation. 

Supposing,  as  in  Jessop's  case,  that  there  is  no  sac,  the 
operation  is  of  the  simplest  nature.  The  foetus  is  removed,  the 
cord  is  divided  and  tied,  a  drainage  tube  is  placed  with  its 
extremity  near  to  the  attachment  of  the  placenta,  and  the  end 
of  the  cord  is  left  hanging  out  of  the  wound.  The  subsequent 
treatment  is  most  important.  The  abdomen  is  kept  dry  by 
repeatedly  sucking  out  extravasated  fluids  through  the  tube ; 
and,  if  necessary,  abdominal  irrigation  is  employed.  The  pla- 
cental debris  are  thus  removed :  should  the  placenta,  or  portions 
of  it,  slough,  it  may  be  wise  to  enlarge  the  abdominal  opening, 
to  permit  of  its  removal  or  facilitate  its  escape. 

Should  it  seem  feasible  to  remove  the  placenta  without 
greatly  adding  to  the  risk,  this  may  be  done.  Martin,  in  his 
successful  case,  did  so.  But  in  most  cases,  and  particularly  if 
the  sac  can  be  shut  off"  from  the  general  cavity,  this  is  not 
advisable.  If  there  is  no  sac,  to  remove  the  placenta  will  rarely 
be  possible,  and  still  more  rarely  proper. 


332  OPERATIONS  FOR  ECTOPIC   GESTATION. 

Intestine  adherent  to  the  sac  at  the  point  elected  for  opening 
must  be  separated  with  great  care  and  dehcacy.  This  is  best 
done  by  peeHng  it  off  with  sponges ;  if  a  cutting  instrument 
must  be  used,  and  it  is  difficult  to  follow  the  line  of  attachment, 
it  is  wiser  to  borrow  extra  tissue  from  the  sac  than  from  the 
bowel.  Indeed,  it  may  be  a  good  plan  to  cut  out  the  adherent 
portion  of  sac  and  leave  it  attached  to  the  bowel,  using  the 
opening  so  made  for  delivery- of  the  foetus. 

"  The  golden  rule  for  the  operation  is,"  says  Tait,  "  to  avoid 
touching  the  placenta."  The  site  of  placental  attachment  is 
not  usually  obscure  in  these  cases.  Dark  coloration  of  the  sac- 
wall,  with  the  ordinary  signs  of  abundant  vascularisation,  and, 
not  infrequently,  intimate  adhesions  to  contiguous  structures, 
mark  the  placental  site.  Every  legitimate  effort  must  be  made 
to  avoid  it ;  but  if  it  cannot  be  avoided,  it  must  be  cut  through. 
As  soon  as  it  is  cut,  its  edges  must  be  grasped  in  large  T-shaped 
compressing  forceps ;  and  haemorrhage  may  be  permanently 
checked  by  carrying  a  shoemaker's  or  chain  suture  around  the 
opening,  and  including  both  placenta  and  sac.  When  the  ends 
are  pulled  tight,  this  form  of  suture  will  cause  puckering  of  the 
gap  to  any  extent  desired,  when  its  edges  may  be  conveniently 
fixed  in  the  wound. 

If  there  is  much  fluid  in  the  sac,  this  may  be  removed,  by 
tapping  or  aspiration,  before  the  incision  is  made,  so  as  to  save 
future  sponging.  The  incision  in  the  sac  is  made  preferably  in 
the  direction  of  the  abdominal  wound.  But  if  avoidance  of 
placenta  or  adherent  intestine  is  gained  by  making  the  incision 
in  another  direction,  this  direction  may  be  followed.  When  the 
foetus  is  extracted  the  sac  collapses,  and  there  is  no  difficulty  in 
bringing  its  cut  margins  to  the  surface. 

During  extraction  of  the  foetus  the  edges  of  the  opening  in 
the  sac  are  pulled  forwards  by  forceps,  so  as  to  guide  the  fluids 
over  the  parietes.  The  cavity  is  cleansed  and  mopped  out,  and 
the  cord  is  left  hanging  out  of  the  wound.  The  edges  of  the 
opening  in  the  sac  are  carefully  stitched  to  the  skin  at  the 
bottom  of  the  wound,  leaving  an  opening  large  enough  to  admit 
the  largest  size  of  drainage  tube,  and  along  side  of  it  the  um- 


OPERATION   FOR   RUPTURE.  333 

bilical  cord.  It  would  be  good  practice  to  surround  the  cord 
with  a  roll  of  gutta-percha  tissue.  The  abdominal  incision  is 
finally  closed  down  to  the  attachment  of  the  sac. 

Sponging  and  sponge-packing  will  have  been  employed  at 
every  step  where  necessary,  to  soak  up  fluid  or  protect  ab- 
dominal organs. 

Supposing  the  sac  is  covered  by  peritoneum — that  is,  sup- 
posing the  ovum  has  developed  between  the  la3^ers  of  the  broad 
ligament — we  may  expect  to  find  the  whole  pelvic  peritoneum 
elevated,  thickened,  and  vascular.  Instead  of  the  thin  fibrous 
tissue,  traversed  by  large  vascular  trunks,  met  with  in  adven- 
titious sacs,  we  here  have  to  deal  with  thick,  succulent,  cellular 
tissue,  abundantly  supplied  with  minute  vessels.  Haemorrhage 
is  therefore  likely  to  be  troublesome,  on  making  the  incision  ; 
but  it  may  be  controlled  in  the  way  recommended.  In  such 
cases,  delivery  by  vagina  may  be  substituted  with  least  dis- 
advantage. 

Free  drainage,  combined  with  irrigation,  and,  if  necessary, 
dilatation  of  the  opening,  to  permit  escape  of  the  separated 
placenta,  include  the  subsequent  details  of  treatment. 

Rarely  is  it  advisable  to  attempt  complete  removal  of  the 
sac.  In  the  early  stages  of  ventral  gestation,  while  the  sac  is 
small  and  its  connections  either  intimate  or  numerous,  it  may 
be  possible  to  shell  the  whole  out.  In  such  proceedings,  how- 
ever, bleeding  may  be  difficult  to  control,  either  because  its 
source  lies  deeply  in  the  pelvis,  or  because  it  arises  from 
numerous  points  of  adhesion  to  intestine  or  other  important 
viscus. 

Operation  for  Rupture  during  Spurious  Labour . — Here  the  plan  of 
operation  is  decided  for  us.  The  foetus  being  removed,  and  the 
extravasated  blood  and  other  fluids  having  been  mopped  up, 
the  rent  in  the  sac  is  examined  for  bleeding  points.  Locking 
forceps  are  placed  on  these,  and  left  attached.  A  deliberate 
examination  of  the  state  of  parts  is  now  instituted.  If  the  rent 
is  in  front,  the  operation  is  concluded  as  if  it  had  been  inten- 
tionally made  there,  by  suturing  its  edge  to  the  parietal  wound. 


334  OPERATIONS  FOR   ECTOPIC   GESTATION. 

If  it  is  behind,  or  so  situated  that  its  hps  cannot  be  brought  to 
the  surface,  a  variety  of  methods  are  possible.  It  is  inadvisable 
to  permit  the  discharges  from  the  sac  to  escape  into  the  ab- 
dominal cavity  ;  therefore,  the  rent  should,  if  possible,  be  closed, 
and  an  opening  made  in  front,  below  the  parietal  wound.  This 
opening  need  not  be  so  large  as  if  the  foetus  had  to  be  delivered 
through  it ;  sufficient  space  to  admit  the  drainage  tube  and  the 
umbilical  cord  is  all  that  is  wanted.  Through  this  opening 
measures  may  be  adopted  to  close  the  rent,  either  temporarily 
by  T-shaped  pressure  forceps,  or  permanently  by  a  continuous 
suture  through  the  infolded  edges.  The  sac  is  then  treated  as  if 
it  had  not  been  ruptured.  It  will  always  be  advisable  to  place 
a  drainage  tube  in  the  abdominal  cavity,  and  retain  it  there  for 
a  day  or  two,  until  there  is  evidence  that  there  is  no  leakage 
from  the  rent. 

Operation  with  a  Dead  or  Decomposing  Foetus. — This  proceeding 
is  usually  called  for  after  the  period  of  false  labour,  when  symp- 
toms arise  which  indicate  danger  to  the  mother.  The  conditions 
which  give  rise  to  these  symptoms  are  very  varied,  and  the 
details  of  the  operation  will  be  similarly  varied.  In  fact,  to 
describe  the  average  course  of  one  operation,  in  the  midst  of 
the  endless  varieties  met  with,  would  be  impossible.  From 
removal  of  a  gangrenous  sac'  containing  a  putrid  ovum,  with 
perhaps  resection  of  bowel,  down  to  simple  opening  and 
drainage  of  an  abscess,  we  must  be  prepared  for  almost  any 
contingency. 

Thornton"  succeeded,  after  much  difficulty,  in  removing 
the  whole  gestation-sac  as  well  as  foetus.  The  cyst-wall  was 
rotten,  and,  during  the  manipulation  necessary  for  separating 
the  abundant  intestinal  adhesions,  rupture  took  place,  and 
clotted  blood,  followed  by  a  withered  foetus,  escaped. 

Nottat  records  a  case  on  which  M.  Boilly  operated,  and  in 
which  intestinal  obstruction  was  present.  The  foetus  had  been 
carried  for  eight  years,  and  the  cyst  was  very  intimately  adherent. 

*  Obstet.  Trans.,  vol.  xxiv. ,  1882,  p.  81. 
t  Prog.  Mdd.,  1884,  xii.,  p.  196. 


OPERATION    WITH  DEAD   FCETUS.  335 

A  loop  of  intestine  was  found  strangulated,  and  the  constriction 
was  divided.  The  patient  died ;  and  after  death  a  second 
strangulation  was  found.  A  preparation  in  the  Bristol  Infir- 
mary museum  shows  strangulation  of  a  double  loop  of  bowel 
by  adhesions  around  a  gestation-sac. 

In  Galabin's^'  case  of  extra -uterine  and  intra -uterine 
gestation  combined,  the  sac  was  so  friable  that  it  could  not 
be  stitched  to  the  abdominal  wall ;  and  death  was  probably 
caused  by  the  uterus,  in  the  premature  expulsion  of  its  own 
foetus,  contracting  away  from  the  extra-uterine  placenta  which 
was  attached  to  its  surface,  and  so  causing  haemorrhage. 

Breudelf  operated  successfully  on  a  case  where  there  was 
absolute  constipation  for  four  weeks.  In  this  case  the  foetus 
was  not  decomposed,  the  placenta  was  almost  separated,  and 
the  operation  presented  no  serious  difficulties. 

Spanton  |  operated  successfully  on  a  case  in  which  symptoms 
of  peritonitis  had  existed  for  two  months.  A  macerated  foetus 
and  putrid  purulent  fluid  were  found  in  the  sac,  and  very  exten- 
sive intestinal  adhesions  were  present.  Drainage  of  the  abdomen 
as  well  as  of  the  sac,  and  daily  irrigation,  were  employed. 

One  of  the  most  remarkable  of  these  cases  was  operated 
upon  with  success  by  the  late  Dr.  Angus  Macdonald,§  The 
woman  at  the  end  of  the  sixth  month  was  seized  with  dysuria 
and  pain  in  the  lower  abdomen ;  three  weeks  later  a  sanious 
vaginal  discharge  appeared,  with  oedema  of  the  left  leg.  Hectic 
supervened,  and  the  patient  was  brought  to  a  very  low  ebb. 
At  the  operation  it  was  found  that  the  cyst  had  opened  into  the 
intestine ;  and  the  foetus  la}^  surrounded  with  faeculent  fluids,  in 
a  sac,  part  of  whose  wall  was  formed  by  intestine.  Resection 
of  the  semi-gangrenous  gut  was  at  once  carried  out,  and  the 
abdomen  closed  after  being  thoroughly  cleansed.  The  patient 
made  an  excellent  recovery. 

In  1887  I  had  to  operate  on  a  patient  in  the  Bristol  Infir- 
mary, with  an  extra-uterine  foetation,  about  five  months  after 

*  Obstet.  Trans.,  1882,  vol.  xxiv.,  p.  8r. 

t  Centralbl.  f.  Gyn.,  Oct.  13th,  1883,  p.  649. 

\  Brit.  Med.  jfourii.,  Jan.  12th,  1884.     §  Ed.  Med.  Journ.,  Feb.,  1884,  p.  697. 


336  OPERATIONS  FOR   ECTOPIC   GESTATION. 

the  period  of  spurious  labour.  The  foetus  lay  in  its  membranes 
quite  free  in  the  abdominal  cavity ;  but  adherent  to  bowel, 
intestines,  and  parietes.  The  adhesions  were  broken  down 
with  great  ease,  not  a  vessel  had  to  be  tied,' and  the  operation 
was  concluded  without  any  difficulty  whatever.  The  mem- 
branes were  quite  intact,  lying  closely  over  the  limbs  and  trunk 
of  the  child.  The  head  was  putrefying.  The  placenta  was 
firmly  attached  over  the  fundus  of  the  bladder  and  was  not 
disturbed.  There  was  not  a  trace  of  foetal  sac.  The  foetus 
appeared  to  be  one  of  about  the  seventh  month.  The  patient 
made  an  excellent  recovery,  the  umbilical  cord  being  removed 
with  the  help  of  daily  rotations. 

No  two  cases  are  alike,  and  no  general  rules  can  be  laid 
down  for  their  treatment.  Litzmann  has  collected  33  cases, 
24  occurring  between  1870  and  1880;  there  were  19  recoveries. 

Before  laying  open  a  sac  which  may  contain  very  putrid 
material,  the  aspirating  needle  should  be  used,  to  draw  off 
sufficient  fluid  to  cause  relaxation  of  the  sac-walls,  and  to 
permit  of  the  site  elected  for  opening  being  drawn  to  the 
surface  by  forceps.  Sponge -packing  around  the  sac  should 
always  be  employed  ;  and  thorough  cleansing  of  the  abdominal 
cavity  ought  to  be  carried  out.  When  the  sac  is  empty,  the 
fingers  should  be  carried  around  it  everywhere,  to  make  certain 
that  there  is  no  strangulation  of  intestine.  The  placenta,  unless 
it  is  loose  or  partially  detached,  ought  not  to  be  disturbed. 

If  there  is  a  suspicion  of  general  peritonitis,  or  if  any  of  the 
fluids  have  escaped  ftom  the  sac,  abdominal  drainage  ought  to 
be  used,  as  well  as  drainage  of  the  sac.  Irrigation  of  the  sac 
with  antiseptic  fluids  is  useful,  both  as  helping  to  remove 
placental  debris,  and  as  protecting  from  septic  absorption. 

It  is  a  great  advantage  in  these  cases  to  find  that  the 
placental  circulation  has  ceased,  because  then  that  body  can  be 
removed  without  risk  of  causing  haemorrhage  or  laying  open  the 
maternal  sinuses  to  the  danger  of  septic  infection.  Unfortunately 
there  are  no  means  of  ascertaining  beforehand  when  the  placental 
circulation  has  ceased.  Experience  is  no  guide  ;  for,  while 
Schroeder  in  one  case  found  obliteration  of  the  vessels  three 


MISSED  LABOUR.  337 

weeks  after  the  death  of  the  foetus,  Depaul,  in  another  case  in 
which  foetal  death  had  occurred  four  months  previously,  found 
the  placental  circulation  still  going  on,  and  lost  his  patient  from 
haemorrhage.  After  the  child  is  dead,  if  there  is  no  urgency  we 
may  wait ;  every  week  that  passes  adds  to  the  probability  that 
obliteration  of  the  placental  vessels  has  taken  place.  On  the 
earliest  appearance  of  troublesome  symptoms,  operation  should 
be  performed. 

These  operations,  properly  conducted,  are  not  so  fatal  as 
might  be  expected.  Thus,  Gaillard  Thomas  saved  four  cases 
on  which  he  operated ;  Tait  has  lost  only  one  out  of  seven  ;  and 
individual  examples  of  most  difficult  and  unpromising  operations 
conducted  to  success  are  daily  becoming  more  numerous. 


OPERATION    FOR    "  MISSED    LABOUR."       PREGNANCY    IN    ONE    HORN 
OF    A    BICORNED    UTERUS. 

Only  a  very  few  examples  of  this  condition  have  been 
recorded,  and  still  fewer  operations.  Some  of  the  cases  might 
be  read  as  so-called  interstitial  pregnancies ;  that  is  to  say,  as 
pregnancies  in  that  part  of  the  tube  which  passes  through  the 
uterus.  Others  might  have  been  true  extra-uterine  pregnancies, 
which  had  forced  their  way  by  ulceration  into  some  part  of  the 
genital  tract.  But  a  sufficient  number  of  cases  have  been 
recorded  by  competent  observers  to  prove  beyond  a  doubt  that 
pregnancy  may  proceed  to  full  term  in  one  horn  of  a  bicorned 
uterus,  and  that  when  labour  comes  on  at  term  it  may  not  result 
in  discharge  of  the  foetus.  Angus  Macdonald  held  that  all 
examples  of  "  missed  labour  "  are  probably  cases  of  uni-cornual 
pregnancy.  Whether  this  be  so  or  not,  it  is  certain  that  the 
anatomical  and  physiological  peculiarities  of  pregnancy  in  one 
horn  of  a  bicorned  uterus  will  explain  most  cases  of  missed 
labour.  If  this  is  not  a  proved  fact,  it  is  certainly  a  good 
working  hypothesis. 

Anatomical  Conditions. — In  the  cases  of  uni-cornual  pregnancy 
which  have  resulted  in  missed  labour,  there  has  always  been 

23 


338  OPERATIONS  FOR  ECTOPIC  GESTATION. 

found  either  complete  absence  of  communication  with  the 
general  cavity,  or  only  a  small  opening  incapable  of  being 
dilated.  The  pregnancy  takes  place  in  an  offshoot  or  diverticu- 
lum of  the  uterine  cavity,  so  to  speak  ;  the  ovum  is  completely 
surrounded  by  uterine  muscular  fibre ;  at  no  part  is  there  tissue 
like  the  cervix,  which  will  soften  and  dilate,  and  uterine  con- 
tractions simply  result  in  compression  of  the  ovum.  The  fibres 
around  the  opening  contract  as  much  as  the  fibres  at  the  fundus  ; 
and  their  contractions  effectually  bar  the  way  against  delivery. 
In  fact,  the  balance  of  muscular  force  is  away  from  the  genital 
canal ;  for  the  sac  is  usually  thickest  below,  the  reverse  of  what 
exists  in  normal  gestation.  In  two  of  the  published  cases  no 
communication  was  discovered  with  the  general  cavity. 

The  shape,  attachment,  and  relations  of  the  tumour  are 
easily  understood.  It  is  not  completely  globular,  but  bluntly 
conical.  Somewhere  on  the  side  opposite  its  uterine  attach- 
ment, and  elevated  as  in  normal  pregnancy,  are  the  uterine 
appendages — ovary,  and  Fallopian  tube  ;  and  the  round  ligament 
may  also  be  observed,  elevated  and  thickened.  The  uterine 
appendages  of  the  opposite  side  are  found  low  down,  attached  to 
the  unaffected  cornu.  The  tumour  does  not  lie  symmetrically, 
but  towards  the  side  from  which  it  originates. 

The  contents  of  the  sac  are — the  dead,  and  perhaps  macerated, 
foetus ;  and  fluids  of  varying  character,  according  as  to  whether 
decomposition  has  advanced. 

Diagnosis. — The  history  of  a  pregnancy  advancing  to  full 
term ;  a  fruitless  labour,  followed  by  symptoms  of  death  of  the 
child ;  an  obliquely-placed  abdominal  tumour,  rounded,  smooth, 
and  movable,  with  a  uterine  cavity  little  or  not  all  increased  in 
depth,  ought  to  suggest  uni-cornual  pregnancy  with  missed 
labour.  Occasionally  there  is  a  discharge  of  decidua  from  the 
unimpregnated  horn  at  term,  and  menstruation  may  occur 
regularly  from  the  time  of  labour. 

A  physical  examination  reveals  a  normal  cervix ;  a  uterus  of 
normal  depth,  closely  attached  to  the  tumour,  and  pushed  to 
the  opposite  side;  and  a  tumour  with  the  characters  just  de- 
scribed.    The  presence  of  a  foetus  is  to  be  looked  for  by  the 


OPERATION  IN  MISSED   LABOUR.  339 

ordinary  means.  In  Litzmann's  case,  the  foetal  head  was  found 
resting  on  the  pelvic  brim.  Finally,  the  uterus  may  be  dilated, 
and  an  opening  looked  for  in  its  interior.  In  Litzmann's  case, 
putrid  fluid  flowed  continuously  from  a  very  small  opening. 

Operative  Treatment. — In  all  cases  the  only  treatment  is  by 
operation;  and  the  best  operation  is  laparotomy,  with  complete 
removal  of  the  sac  and  its  contents.  I  know  of  only  five  cases 
of  operation,  the  operators  being  Salin  of  Stockholm,  Litzmann, 
Sanger,  Wiener,  and  Macdonald.  The  last  operator  has  given 
a  particularly  clear  and  full  account  of  his  case ;  *•'  and  has,  at 
the  same  time,  summarised  and  reviewed  other  cases.  The 
operation  was  practically  identical  in  each  case,  and  four  of  the 
five  cases  recovered.  Wiener's  caset  occurred  in  the  end  of 
1884,  and  was  not  known  to  Macdonald.  He  treated  the  stump 
by  the  intra-peritoneal  method,  and  got  a  favourable  result. 
Prof.  Schultze  of  Jena  I  has  amputated  one  half  of  a  bicorned 
uterus  in  which  the  placenta  was  retained.  The  child  was  born  at 
the  seventh  month.  The  midwife  had  torn  away  the  cord  in  her 
efforts  to  remove  the  adherent  placenta.    The  patient  recovered. 

The  operation  is  of  the  simplest  possible  nature.  The  tumour 
is  delivered  through  the  incision,  clamped  by  a  wire  serre-nceud 
at  its  neck,  and  cut  away.  The  pedicle  is  trimmed  and  dressed 
exactly  as  in  Porro's  operation. 

As  the  fluids  in  the  cyst  may  be  putrid,  the  tumour  should, 
if  possible,  be  delivered  without  being  tapped.  But  if  the  cyst 
is  very  large,  there  is  no  objection  to  the  removal  of  fluid  by 
tapping,  provided  the  site  of  puncture  is  carefully  guarded.  In 
every  case,  to  prevent  the  sudden  emptying  of  the  sac  over  the 
abdomen  as  it  is  cut  off  above  the  clamp,  a  second  clamp  should 
be  placed  above  the  first,  and  the  pedicle  divided  between  them. 

*  Ed.  Med.  Joxmi.,  April,  1885.       t  Anhiv.  f.  Gyndh.,  bd.  xxxvi.,  heft.  2. 
+  Deutsche  med.    Woch.,  Nov.  4th,  1886. 


23 


Section   VI. 


OPERATIONS   ON   THE   STOMACH, 


A  CONSIDERABLE  number  of  operations  are  now  performed  on  the 
digestive  organs.  Most  of  these  are  undertaken  on  account  of 
some  obstruction  to  the  passage  of  ahment  or  excrement ;  and 
are  chiefly  of  the  nature  of  resections  of  new  growths,  removal 
of  various  causes  of  obstruction  or  strangulation,  and  the 
establishment  of  fistulae  above  constrictions  which  prevent  the 
discharge  of  excrement. 

For  the  performance  of  these  operations,  the  surgeon  must 
be  familiar  with  a  number  of  special  technical  manipulations, 
some  of  them  of  great  delicacy.  It  is  essential  also  that  he 
should  have  an  acquaintance  with  the  topography  of  the  viscera, 
not  only  anatomical,  such  as  may  be  acquired  in  dissecting- 
rooms,  but  also  practical,  such  as  may  be  picked  up  in  the 
deadhouse.     The  fingers,  inserted  through  openings  made  in  the 


SURGICAL  ANATOMY.  341 

parietes,  are  made  to  explore  the  cavity  in  all  directions,  giving 
a  practical  and  tactile  acquaintance  with  the  position  of  the 
viscera,  as  well  as  with  their  consistency,  shape,  distance  from 
the  surface,  and  many  other  peculiarities.  I  would  strongly 
urge  the  importance  of  this  post-mortem  study  of  the  abdominal 
viscera  by  touch.  There  is  no  substitute  for  it  but  great 
practice  in  operating ;  and  the  experience  so  gained  is  liable  to 
be  costly  to  the  patients.  Every  operation  ought  first  to  be 
performed   on   the   cadaver. 

I  believe  it  is  not  generally  appreciated  how  much  of  the 
abdominal  cavity  may  be  explored  by  a  single  finger  inserted 
through  an  opening  an  inch  in  length.  In  a  subject  of  average 
size,  through  an  opening  midway  between  the  pubes  and 
the  umbilicus  we  may  examine  the  whole  of  the  true  pelvis, 
and  the  abdominal  cavity  as  high  as  the  kidneys  laterally,  and 
the  greater  curvature  of  the  stomach  in  the  middle  line.  With 
two  fingers  a  greater  distance  may  be  reached.  The  topography 
of  the  abdomen,  from  a  surgical  point  of  view,  is  best  learnt  in 
this  way.  Anatomical  knowledge  tells  us  where  to  make  an 
incision  in  order  to  reach  a  certain  organ ;  but  the  educated 
fingers  inserted  through  this  incision  must  recognise  the  organ, 
and  bring  it  within  reach  of  the  operator.  The  hollow  viscera 
are  not  always  to  be  found  in  their  anatomical  positions.  Indeed, 
when  there  is  occasion  to  operate  on  any  part  of  the  intestinal 
tract,  the  disease  which  necessitates  operation  will  usually  be 
found  to  have  been  a  cause  of  displacement.  This  is  another 
reason  for  the  cultivation  of  diagnosis  by  touch. 

The  characters  of  the  tissues  themselves  are  peculiar  and 
unique,  from  a  surgical  point  of  view.  To  deal  with  any  part 
of  some  twenty  odd  feet  of  hollow  tube  containing  septic  ma- 
terial, and  lying  in  a  closed  cavity  which  is  perfectly  aseptic  but 
peculiarly  amenable  to  septic  influences,  is  a  problem  in  practical 
surgery  which  it  is  not  easy  to  solve.  And  in  dealing  with  the 
walls  of  this  tube,  the  material  we  have  to  work  upon  is  not 
the  most  satisfactory  for  surgical  manipulations. 

In  every  operation  involving  a  solution  of  continuity  of  the 
digestive    apparatus,  special   precautions  have  to  be  taken  to 


342  OPERATIONS  ON   THE  STOMACH. 

prevent  the  escape  of  their  contents  into  the  peritoneal  cavity. 
Its  blood-supply  is  conveyed  in  a  delicate  meshvvork  which  is 
easil}'  torn  across,  and  gangrene  of  portions  of  the  bowel  may  be 
induced  by  injury  to  mesentery  or  omentum  and,  in  certain  situ- 
ations, even  to  parietal  peritoneum.  Lastly,  in  the  closure  of 
wounds,  we  have  to  deal,  on  the  one  hand,  with  the  thin  serous 
and  muscular  coats,  which  are  readily  torn  through  by  needles 
or  sutures ;  and,  on  the  other,  with  mucous  membrane  which 
secretes  fluids  inimical  to  the  vitality  of  the  uniting  media. 

Topographical  and  Surgical  Anatomy  of  the  Stomach. — The  position 
of  the  stomach  as  ordinarily  described  in  text-books  is  not  con- 
sistent with  that  laid  down  by  the  accurate  researches  of  Luschka, 
Braune,  Warner,  Lesshaft,  and  others.  Nor  are  these  more  recent 
descriptions  perfectly  harmonious  on  all  points.  The  stomach 
is  a  movable  organ,  varying  its  position  within  considerable  and 
not  very  definite  limits;  and  these  changes  of  position  are  usually 
most  marked  under  circumstances  such  as  demand  operation. 

It  is  only  when  the  stomach  is  empty  that  its  surfaces  are 
directed  forv/ards  and  backwards,  and  its  borders  upwards  and 
downwards.  Leuf  describes  the  stomach,  when  fully  contract- 
ed, as  being  "tubular.''  Its  external  measurement  is  then  no 
larger  than  a  moderately  distended  jejunum ;  the  mucous  mem- 
brane is  corrugated  into  deep  folds,  and  the  muscular  coat 
greatly  thickened.  In  this  empty  state  of  the  stomach  the 
pylorus  is  frequently  found  open,  so  that  water  poured  into  it  may 
at  once  run  into  the  duodenum.  As  it  fills,  the  lower  border  not 
only  descends  in  the  abdomen,  but  also  rotates  forward  around 
the  long  axis  of  the  viscus,  thus  bringing  the  anterior  surface 
superior,  and  the  posterior  surface  inferior.  In  some  cases  this 
rotation  may  be  so  considerable  as  to  bring  the  lower  border 
fully  to  the  front,  while  the  upper  border  is  behind. 

About  five-sixths  of  the  stomach  lie  on  the  left  of  the  middle 
line,  one-sixth  or  less  being  on  the  right.  During  distension  the 
cardiac  extremity  rises  upwards  under  the  diaphragm,  increasing 
the  size  of  the  pouch,  but  causing  little  increase  of  the  pro- 
jection towards  the  left.      The  bulk  of  the  organ  lies  directly 


SURGICAL  ANATOMY.  343 

behind  the  cartilages  of  the  fifth  and  sixth  ribs ;  the  rest,  with 
the  pylorus,  is  situated  in  the  epigastrium.  Most  observers 
place  the  pylorus  exactly  in  the  middle  line ;  sometimes  it  lies 
a  little  to  the  right. 

The  anterior  surface  of  the  stomach  is  in  relation  with  the 
diaphragm,  with  the  under  aspect  of  the  left  lobe  of  the  liver, 
with  the  internal  surfaces  of  the  fifth,  sixth,  seventh,  eighth, 
and  ninth  left  ribs  and  their  cartilages,  and  with  the  anterior 
abdominal  wall.  It  is  accessible  on  the  anterior  surface,  where 
it  is  in  contact  with  the  parietes.  The  accessible  area  is  in  a 
triangular  space  bounded  by  the  ribs,  the  edge  of  the  liver,  and 
a  line,  nearly  transverse,  which  moves  upwards  or  downwards 
according  as  the  stomach  is  empty  or  full.  When  moderately 
distended,  the  lower  limits  of  the  stomach  may  be  on  a  level 
with  the  tip  of  the  tenth  rib-cartilage;  when  empty,  the  stomach 
may  disappear  from  this  triangular  area,  and  be  completely 
retracted  behind  the  bony  margins  of  the  upper  abdomen. 
Tillaux  points  out  that  the  tip  of  the  ninth  rib -cartilage  is 
prominent  and  movable,  being  attached  to  the  eighth  cartilage 
by  a  short  ligament.  It  is  known  by  its  prominence,  and  by  a 
sense  of  grating  which  it  gives  when  it  is  rubbed  on  the  upper 
cartilage.  He  would  make  the  tip  of  the  ninth  rib  a  landmark 
for  making  out  the  lower  limit  of  the  stomach,  and  recommends 
it  as  a  fixed  point  to  reckon  from  in  gastric  surgery. 

In  many  cases  of  distension  of  the  stomach,  the  limits  of  the 
organ  may  be  accurately  mapped  out  by  percussion;  and  other 
modes  of  assisting  diagnosis,  by  artificially  distending  the  cavity 
with  gas  or  fluid,  are  employed. 

The  connections  and  vascularisation  of  the  stomach  are  of 
surgical  importance.  The  gastro- splenic  ligament  has  more 
bearing  on  the  surgery  of  the  spleen  than  of  the  stomach.  The 
lesser  omentum,  passing  between  the  upper  border  of  the 
stomach  and  the  under  surface  of  the  liver,  requires  fuller 
notice.  It  contains  in  its  folds  the  gastric  artery,  which  is  the 
chief  source  of  blood-supply  to  the  stomach ;  and  the  hepatic 
artery,  coursing  along  the  front  border  of  the  foramen  of  Winslow, 
which  gives  off  the  important  pyloric,  gastro-duodenal,  and  right 


344  OPERATIONS  ON   THE  STOMACH. 

gastro-epiploic  branches.  The  importance  of  these,  both  as  sup- 
plying blood  to  the  stomach,  and  as  being  in  the  region  of  certain 
surgical  operations  on  the  pylorus,  is  self-evident.  The  portal 
vein  and  the  common  bile  duct  also  lie  in  the  lesser  omentum. 

The  neighbourhood  to  the  pylorus  of  the  vena  portae,  the 
pancreas,  the  splenic  vein,  and  the  neck  of  the  gall-bladder, 
must  be  borne  in  mind  during  surgical  manipulations. 

The  attachment  of  the  great  omentum  to  the  greater  curva- 
ture of  the  stomach  is  also  of  surgical  importance.  It  requires 
division  in  circular  resections  of  parts  of  the  stomach,  and  in 
such  operations  as  may  be  performed  on  the  posterior  surface  of 
that  organ.  The  transverse  meso-colon  itself  is  not  beyond  the 
reach  of  danger  in  operations  on  the  pylorus ;  and  as  it  contains 
between  its  layers  the  vessels  which  supply  the  transverse  colon, 
any  wound  of  it  is  fraught  with  risk  to  the  vitality  of  that  bowel. 
This,  however,  is  not  likely  to  take  place  unless  adhesions  exist, 
binding  the  parts  together,  and  the  pylorus  is  displaced  down- 
wards. In  no  fewer  than  five  cases  has  gangrene  of  the  colon 
resulted  from  injury  to  the  meso-colon. 

The  vascular  anastomosis  around  the  stomach  is  so  free  that 
gangrene  of  portions  of  its  walls  need  not  be  counted  among 
the  risks  of  operation.  It  may  be  as  well,  where  a  choice  is 
given,  to  make  an  incision  along  the  course  of  the  chief 
branches — that  is,  transversely  to  the  long  axis ;  but  this  is  not 
of  great  importance. 

The  operations  performed  on  the  stomach  are  the  folloAving: — 
Gastrostomy,  or  the  artificial  formation  of  a  fistula  for  the  intro- 
duction of  food ;  Gastrotomy,  incision  of  the  walls  of  the  stomach 
for  the  removal  of  foreign  bodies  or  tumours  ;  Gastrorraphy,  or 
operative  closure  of  a  fistula,  or  ulcer,  or  wound ;  and  Pylo- 
rectomy,  partial  gastrectomy,  or  excision  of  portions  of  the 
stomach  for  new  growth.  Besides  these,  various  operations 
are  performed  for  pyloric  obstruction ;  such  as,  operative 
dilatation  of  the  pylorus,  and  the  formation  of  fistulae  between 
stomach  and  intestines,  and  between  intestines  and  the 
parietes :  and  these  will  here  be  considered. 


Gastrostomy. 

Gastrostomy  {^/aaTijp — stomach,  and  (TTo'/ta — mouth)  is  the 
establishment,  by  operation,  of  a  fistula  through  the  ab- 
dominal and  gastric  walls  for  the  purpose  of  introducing 
nourishment. 

History. — In  1837  Egebert  (or  Egeberg),  a  surgeon  in  the 
Norwegian  military  service,  read  a  paper  before  a  medical 
society  in  Christiania  in  which  he  strongly  recommended  the 
practice  of  this  operation  for  stricture  of  the  oesophagus.  He 
based  his  recommendation  on  the  frequently  successful  results 
of  the  treatment  of  wounds  in  the  stomach,  and  on  the  proved 
compatibility  of  gastric  fistula  with  healthy  existence.  He 
described  the  operation  with  great  minuteness,  and  with  a 
scientific  foreknowledge  which  leaves  little  to  be  added  to  the 
modern  descriptions  of  it.  He  even  advised  preliminary  sutur- 
ing of  the  stomach  to  the  abdominal  wall  (since  called  Howse's 
method),  so  that  adhesions  might  form  before  the  opening  was 
made.  This,  however,  was  then  a  recognised  procedure  in  the 
opening  of  cysts  of  the  liver  and  other  organs.  Egebert's  paper 
was  not  published  till  1841.''' 

About  this  time  Blondlot,  in  his  investigations  on  the  pro- 
cess of  digestion,  had  succeeded  in  forming  gastric  fistulae  in 
the  lower  animals.  A  little  later,  Watson,  reasoning  on  the 
same  lines  as  Egebert,  sought  to  justify  gastrostomy  in  insuper- 
able contractions  of  the  oesophagus.  All  this  was  speculation  : 
no  one  had  as  yet  performed  the  operation. 

To  Sedillot,  who,  in  1846,  came  forward  in  strong  advocacy 
of  the  procedure,  is  due  the  merit  of  having  first  performed  the 
operation  on  a  human  being.  He  gave  it  the  name  "gastros- 
tomy." His  writings  exhibit  the  practical  knowledge  of  the 
trained  surgeon  and  anatomist,  and  they  are  brimful  of  earnest 
enthusiasm.  The  indications  for  operation  he  considered  to  be 
*  Norsk  Magdzin  for  Lagevidcnskahen. 


346  GASTROSTOMY 

SO  straightforward  and  so  favourable,  that  he  expressed  surprise 
that  no  one  before  him  had  suggested  it.  Apparent!)^,  therefore, 
Sedillot  was  ignorant  of  Egebert's  proposal.  In  his  indications 
for  operation  he  includes  a  wide  range  of  diseases.  Besides 
stricture,  he  includes  congenital  absence  of  the  cesophagus ; 
tumours  in  the  neighbourhood  of  the  cesophagus  and  pressing 
upon  it ;  tumours  of  its  walls ;  and  even  wounds,  ulcers,  and 
inflammatory  softenings,  where  the  result  to  be  attained  was 
merely  temporary  rest.  In  one  of  his  papers  he  records,  in 
support  of  the  operation,  successful  experiments  upon  animals. 
Individual  surgeons,  and  on  one  occasion  the  united  opinion  of 
a  whole  societ}^,  were,  however,  against  him.  In  1839  he  had 
performed  his  first  operation  on  a  man  far  gone  with  cancerous 
stricture,  with  a  fatal  result  in  twenty-five  hours.  In  1853  he 
again  operated  with  fatal  result  after  ten  days.  A  third  case, 
also  fatal,  is  recorded  in  his  work  on  Operative  Surgery.  In  spite 
of  these  failures  and  of  much  opposition,  Sedillot  maintained 
the  propriety  of  the  operation. 

Streubel,  while  objecting  to  the  operation  for  cancerous 
stricture,  considered  that  it  might  be  justifiable  in  cicatricial 
contraction;  but  he  did  not  operate.  In  1853  Fenger,  quite 
originally,  and  after  careful  preparation,  operated  with  fatal 
result  after  fifty-eight  hours.  Nelaton,  in  his  work  on  Surgical 
Pathology,  speaking  of  the  operation,  advises  that  it  should  be 
performed  in  two  stages,  and  that  it  should  be  limited  to  cases 
of  uncomplicated  cicatricial  contraction  of  the  oesophagus  in 
young  subjects. 

The  operation  continued  to  languish.  In  1858  Cooper 
Forster  of  Guy's  Hospital  operated  for  the  first  time  in  England, 
but  without  success.  In  1859  he  again  operated,  with  like 
result ;  and  one  or  two  isolated  cases  occurred  in  the  next  few 
years.  Among  those  who  favoured  the  operation,  the  opinion 
was  very  generally  held,  that  it  ought  to  be  restricted  to  cases 
of  cicatricial  contraction.  Giinther  and  Gross,  in  particular, 
identified  themselves  with  this  view.  In  1866  Bryant  and 
Curling  operated,  both  without  success.  Indeed,  with  the 
exception  of  a  partial  success  by  Kiister  of  Berlin,  no  satisfactory 


THE  AIM  OF  THE   OPERATION.  347 

result  was  achieved  till  1874,  when  Sydney  Jones  of  St.  Thomas's 
Hospital  performed  his  third  operation. 

From  this  time  the  operation  rapidly  advanced  in  success 
and  repute.  The  improved  results  arose  partly,  no  doubt,  from 
earlier  operation  ;  but  chiefly  from  a  better  understanding  of  the 
technics  of  abdominal  surgery.  What  influence  the  general 
modern  practice  of  operating  in  two  stages,  as  originally 
suggested  by  Egebert,  advised  by  Nelaton,  and  independently 
re-introduced  by  Howse,  may  have  had  upon  the  operation,  it  is 
difficult  to  say.  Zesas,"'-'  whose  monograph  on  Gastrostomy  is 
one  of  the  most  important  which  has  yet  appeared,  is  not 
in  favour  of  the  operation  in  two  stages.  He  considers  that  it 
interferes  with  success,  by  unnecessarily  prolonging  the  starvation 
and  weakening  the  patient  :  the  improved  results  he  attributes 
to  antiseptics.  However  performed,  there  is  no  doubt  that  the 
operation  has  now  an  assured  foothold  among  legitimate 
measures   of    surgical   relief. 


THE    AIM    OF    THE    OPERATION. 

The  immediate  purpose  of  gastrostomy  is,  to  establish  a 
fistula,  which  traverses  the  walls  of  the  stomach  and  the 
abdomen,  between  the  cavity  of  the  stomach  and  the  outer  air. 
The  remote  and  permanent  purpose  is,  to  carry  nourishment  into 
the  stomach  through  this  fistula.  The  reason  for  the  operation 
exists  in  some  insuperable  obstruction  in  the  digestive  tract 
above  the  stomach  which  prevents  the  introduction  of  food,  or 
in  some  condition  of  the  tract  which  renders  the  introduction  of 
food  dangerous  to  life.  The  whole  motive  is,  therefore,  to 
prevent  death  by  starvation.  In  some  cases  the  prevention  of 
death  may  be  nothing  more  than  a  prolonging  of  life,  as  in  those 
cases  where  life  is  already  doomed  on  account  of  malignant 
disease.  In  other  cases,  the  operation  may  have  results 
synonymous  with  permanent  cure. 

*   "Die  Gastrostomie  und  ihre  Resultate."     Archiv.  f.  Klin.  Chiv.,  1885, 
bd.  xxxii.  ;   heft.  i. 


348  GASTROSTOMY. 

Conditions  for  which  the  Operation  may  be  Performed. — The  actual 
conditions  for  which  the  operation  may  be  performed  are  the 
following  : 

1.  Cancerous  stricture  of  the  oesophagus. 

2.  Cicatricial  contraction  of  the  oesophagus. 

3.  Obstruction  by  the  pressure  of  growths  outside  the 
oesophagus. 

4-  Malignant  disease  in  the  pharynx  or  the  mouth. 

5.  Ulcerative,  chemical,  or  traumatic  destruction  of  the 
walls  of  the  oesophagus. 

6.  Congenital  closure  of  the  oesophagus. 

Cancerous  Stricture  of  the  oesophagus  is  nearly  always  of  the 
epitheliomatous  variety.  Of  57  cases  collected  by  Butlin,  53 
were  epitheliomatous,  2  were  scirrhous,  i  was  encephaloid,  and  i 
was  colloid.  It  is  most  common  in  males  after  middle  life.  It 
would  appear  (though  this  has  been  disputed)  that  it  is  most 
frequently  situated  in  the  lower  half  of  the  tube.  Out  of 
20  cases,  it  was  found  in  the  lower  and  middle  portions  of  the 
gullet  in  14,  in  the  middle  in  4,  and  in  the  upper  third  in  2. 
Professor  Harrison  Allen,*  from  an  analysis  of  a  considerable 
number  of  cases,  concludes  that  the  parts  most  liable  to  stenosis 
lie  behind  the  cricoid  cartilage  and  the  left  bronchus.  Morell 
Mackenzie  found,  out  of  100  cases,  that  in  44  the  disease  lay  in 
the  upper  third,  f  Butlin  j  says  that  while  the  disease  is  unusual 
in  the  middle  portion,  it  occurs  with  almost  equal  frequency  in 
the  upper  and  lower  halves.  Scirrhus  may  extend  into  the 
oesophagus  from  the  stomach. 

The  narrowing  is  caused  partly  by  the  ingrowth  of  the 
epitheliomatous  nodules,  but  it  is  more  of  the  nature  of  a  want  of 
distensibility  than  of  actual  constriction.  The  new  growth  infil- 
trates the  tissues  as  they  lie  normally  undilated,  and  prevents 
their  becoming  dilated  by  the  passing  food.  Spasmodic  con- 
traction, with  hypertrophy  of  the  muscular  tissue,  increases  the 
difficulty.     The  growth  of  the  tumour  is  so  irregular  that  the 

*  Agnew's  Surgery,  vol.  ii. ,  p.  1019.     t  Dis.  of  Throat  and  Nose,  vol.  ii.,  p.  88. 
I    Operat.  Surg,  of  Malig.  Dis. ,  p.  207. 


STRICTURE   OF  THE   GULLET.  349 

open  passage  is  usually  very  devious.  At  parts  there  is  ulcera- 
tion, extending  sometimes  completely  through  the  tube  and 
causing  perforation.  Indeed,  perforation  is  one  natural  termi- 
nation of  the  disease ;  though  starvation  and  haemorrhage, 
perhaps,  are  more  frequently  the  immediate  causes  of  death. 
Not  a  few  cases  have  died  from  perforation  produced  by  the 
passage  of  bougies ;  the  aorta,  the  left  bronchus,  and  the 
pleura,  have  in  this  way  been  entered. 

Fibrous  ov  Organic  Stricture,  also  known  as  cicatricial  contrac- 
tion, is  usually  a  sequence  of  ulceration  caused  by  the  swallowing 
of  caustic  fluids  or  very  hot  water.  It  may  follow  other  forms 
of  ulceration,  particularly  the  syphilitic.  Constant  traumatic 
irritation  or  injury,  as  in  sword-swallowing,  may  also  produce 
non-malignant  stricture. 

The  stricture  following  the  swallowing  of  caustic  substances 
usually  begins  high  up  in  the  gullet,  and  extends  a  considerable 
way  downwards.  It  is  very  rarely  annular.  The  mucous 
membrane  is  replaced  by  a  grey  or  bluish-grey  tissue  of  a 
peculiarly  hard  and  resisting  nature.  The  muscular  layer  is 
rarely  involved.  Stenosis  after  syphilitic  ulceration  is  usually 
high  up,  and  presents  characters  very  similar  to  those  following 
traumatism. 

The  passage  through  the  stricture  is  devious,  but  not  to  such 
an  extent  as  in  epithelioma.  Before  stenosis  is  extreme,  a  bougie 
passes  down  it  with  increasing  difficulty  as  more  of  its  length  is 
engaged.  Sacculation  in  this,  as  in  the  previous  form,  is  often 
found  in  the  gullet  above  the  constriction. 

Tumours  outside  the  Gullet  may  press  upon  it  to  such  an  extent 
as  to  cause  almost  insuperable  obstruction  to  deglutition.  Such 
are :  growths  in  the  neck  or  thorax,  aneurisms  of  the  aorta  or 
the  innominate  artery,  and  some  diseases  of  the  larynx.  Dislo- 
cation backwards  of  the  sternal  end  of  the  clavicle  is  said  by  Sir 
Astley  Cooper  to  have  been  a  cause  of  extreme  dysphagia  ;  and 
I  have  seen  a  mahgnant  growth,  apparently  springing  from  the 
sterno-clavicular  articulation,  produce  great  difficulty  in  swal- 
lowing. Most  of  these  and  similar  cases  are,  however,  usually 
amenable  to  other  forms  of  treatment  than  gastrostomy. 


350  GASTROSTOMY. 

Tumours  in  the  walls  of  the  oesophagus,  other  than  cancer, 
are  extremely  rare.  Fibroma,  sarcoma,  and  lipoma  are  found 
both  sessile  and  pedunculated.  Polypoid  growths  are  most 
common.  A  foreign  body,  becoming  impacted  and  surrounded 
by  inflammatory  adhesions,  may  cause  obstruction,  but  is  best 
treated  by  other  means. 

Malignant  Disease  in  the  Pharynx  or  the  Mouth  is  very  rarely  an 
obstruction  to  swallowing.  Mr.  Whitehead  of  Manchester  has 
performed  successfully  the  operation  of  gastrostomy  for  cancer 
recurring  in  the  mouth  and  pharynx  after  removal  of  the  tongue ; 
and  a  few  operations  have  been  performed  for  primary  malignant 
disease  in  the  mouth  and  pharynx. 

Ulceration  of  the  (Esophagus  which  refuses  to  heal  in  spite  of 
prolonged  treatment  may  justify  the  operation,  on  the  ground 
of  setting  the  parts  at  rest.  An  extensive  destruction  of  the 
mucous  membrane,  as  a  consequence  of  swallowing  corroding 
fluids,  may  do  away  with  the  power  of  deglutition,  or  may 
render  the  performance  of  the  act  dangerous  to  life.  In  such  a 
case,  if  the  patient  suffers  from  inanition  in  spite  of  rectal 
alimentation,  operation  may  be  indicated.  In  syphilitic  and 
other  forms  of  ulceration  the  operation  may,  on  similar  grounds, 
be  called  for. 

Congenital  Absence  or  Closure  of  the  CEsophagus  is  sometimes 
described  as  an  indication  to  operation.  The  condition  is,  how- 
ever, so  rare,  and  the  chances  of  its  being  discovered  in  time 
are  so  remote,  that,  for  this  end,  the  operation  is  not  likely  to 
be  frequently  performed. 

DIAGNOSIS    OF    CESOPHAGEAL    OBSTRUCTION. 

The  subjective  signs  of  stricture  of  the  gullet  are  chiefly 
those  of  difficulty  of  swallowing.  At  first,  with  solid  food, 
there  is  a  sense  of  some  impediment  to  deglutition,  with  un- 
easiness referred  to  the  neck  or  chest.  It  is  gradually  found 
that  comfort  is  attained  only  by  swallowing  small  morsels. 
Soon  discomfort  merges  into  difficulty,  and  difficulty  advances 
to   impossibility  as  far   as   solid   foods   are  concerned.      Then 


DIAGNOSIS   OF   (ESOPHAGEAL   OBSTRUCTION.  351 

liquid  foods  only  can  be  swallowed.  With  these  also  difficulties 
arise.  They  are  swallowed  only  in  small  amount,  and  quan- 
tities are  returned  after  repeated  and  prolonged  attempts  at 
deglutition.  A  feeling  of  nausea,  sometimes  culminating  in 
vomiting,  is  often  present.  At  times  there  is  considerable 
suffering,  perhaps  amounting  to  a  sort  of  anguish,  with  palpi- 
tation and  a  sense  of  suffocation.  All  these  S3'mptoms  go  on 
increasing  till  absolute  inability  to  swallow  food  of  an}'  sort  is 
produced,  and  death  from  inanition  stares  the  patient  in  the 
face. 

Pain  in  the  part  affected,  and  radiating  towards  the  stomach 
and  the  mouth,  is  frequently  complained  of.  The  pain  is  in- 
creased by  spasmodic  contraction  of  the  parts  during  the 
attempts  at  swallowing.  Tenderness  on  pressure  may  be 
present ;  and  this  tenderness  is  usually  more  marked  if  there 
is  thickening  of  the  outlying  tissues. 

In  the  intervals  there  is  a  regurgitation  of  mucus,  mixed  in 
some  cases  with  pus  or  blood.  Such  discharges  are  frequently 
most  offensive  :  in  advanced  cases  the  foetor  is  simply  horrible. 
Signs  of  digestive  disturbance,  such  as  flatulence,  colic,  con- 
stipation, or  diarrhoea,  are  alwa5^s  present. 

With  the  progress  of  the  disease,  the  patient  rapidlj^  and 
surely  loses  ground.  He  becomes  thin,  wan,  and  anxious  ;  his 
strength  leaves  him,  so  that  he  cannot  make  the  slightest 
exertion  without  feeling  exhausted  ;  his  limbs  swell  when  he 
stands,  or  even  when  he  sits;  and  he  dies  of  starvation,  in  a 
state  of  physical  prostration  and  mental  gloom  which  is  most 
painful  to  witness.  Nutrient  enemas,  even  when  selected  and 
administered  with  the  utmost  judgment  and  care,  seem  only  to 
prolong  the  agony. 

The  objective  signs  are  obtained  by  the  passage  of  bougies 
and  by  auscultation  of  the  oesophagus. 

Obstruction  to  the  passage  of  the  bougie  is  the  final  con- 
firmation of  stricture  or  narrowing  of  the  gullet.  The  instru- 
ment must  be  soft  and  flexible,  and  it  must  be  passed  with 
great  delicacy.  Several  varieties  of  suitable  instruments  are 
in  use ;    none  are  superior  to  the   soft  French  bougie  a  boule. 


352  GASTROSTOMY. 

I  believe  that  passage  of  the  oesophageal  bougie,  in  cases  of 
stricture,  is  not  always  regarded  with  the  gravity  which  it 
demands.  I  was  present  when  a  patient  dropped  dead  off  a 
chair  while  a  distinguished  surgeon  was  passing  the  oesophageal 
bougie :  an  aneurism  of  the  aorta  was  found  ruptured.  I  have 
known  of  two  others  where  death  resulted  from  perforation  of 
the  pleura  at  the  hands  of  skilled  surgeons.  The  slightest  force 
is  therefore  to  be  strongly  condemned. 

Some  idea  of  the  nature  of  the  stricture  may  be  derived 
from  the  passage  of  the  instrument.  Its  position  in  the  gullet 
may  be  deduced  from  the  distance  which  the  instrument 
traverses  without  being  checked,  as  measured  from  the  teeth. 
If  the  stricture  is  cancerous,  blood  or  pus,  or  even  small  shreds 
of  tissue,  may  be  found  on  the  instrument  when  withdrawn  ;  if 
it  is  simply  fibrous,  the  instrument  is  covered  with  mucus  only. 
In  fibrous  constriction,  the  bougie  is  grasped  with  increasing 
tightness  as  it  is  passed  along ;  in  malignant  disease,  the 
obstruction  is  suddenly  met,  and,  once  passed,  does  not  produce 
increasing  difficulty. 

Further  assistance  in  diagnosing  the  nature  of  the  obstruc- 
tion is  derived  from  the  history.  In  all  cases  this  must  be 
carefully  gone  into.  The  interpretations  are  obvious,  and  need 
not  be  particularised.  Spasmodic  contractions  of  the  gullet  as 
found  in  young  hysterical  females  need  only  be  mentioned  as  a 
possible,  but  improbable,  source  of  error. 

As  a  supplementary  aid  to  passage  of  the  bougie,  we  may 
employ  the  method  of  auscultation  of  the  oesophagus  as  intro- 
duced by  Hamburger  in  1867.*  Morell  Mackenzie, +  Clifford 
Allbutt,t  Zenker, §  and  others,  have  employed  and  favourably 
commented  upon  this  method.  Though  its  inventor  claimed 
too  much  for  it,  there  need  be  no  dispute  that  by  auscultation 
over  the  spine  we  can  detect  the  existence  of  an  obstruction 
to  deglutition,  and,  within  somewhat  uncertain  limits,  fix  upon 
its  site.     Familiarity  with  the  normal  sounds  of  deglutition  must 

*  Klinik  (lev  GLsophagus-Krankheiten,  1871. 

t  Lancet,  May  30th,   1874.  \  Brit.  Med.  Journ.,  Oct.   2nd,  1875. 

§  Ziemssen's  Cyclopadia,  vol.  viii.,  p.   12. 


MORTALITY.  353 

first  be  acquired  in  healthy  subjects.  The  whole  length  of  the 
gullet,  from  the  fifth  cervical  to  the  ninth  dorsal  vertebra,  must 
be  examined  with  the  stethoscope  over  the  spine  during  suc- 
cessive acts  of  deglutition  of  the  same  substance,  liquid  or 
solid.  The  character  of  the  sound  it  is  impossible  to  describe  : 
it  is  said  to  resemble  the  word  "glou-glou"  pronounced  in  a 
loud  whisper.  An  obstruction  to  the  descent  of  the  food  in  the 
gullet  is  inferred  if  there  is  marked  diminution  or  cessation  of 
the  sound  at  any  part  ;  if  there  are  prolonged  gurgling  or 
clucking  sounds ;  or  if  the  sound,  arrested  at  a  given  spot, 
passes  upwards  again  as  the  material  is  regurgitated.  After 
special  training,  diagnosis  by  auscultation  may  be  satisfactory 
and  final ;  with  most,  it  is  merely  a  confirmation  of  other 
methods.  Probably  most  clinicians  would  agree  with  the 
opinion  recently  expressed  by  Ogston,  that  the  value  of 
auscultation  is  chiefly  in  showing  delay  in  the  downward 
passage  of  the  material  swallowed. 

The  oesophagoscope  is  not  of  much  practical  value ;  its 
mirrors  are  obscured  by  the  mucus,  which  is  abundantly 
secreted  when  the  instrument  is  passed. 

MORTALITY    AND    APPRECIATION. 

Gross''''  and  Zesasf  have  collected  elaborate  statistics  of  the 
results  of  gastrostomy.  Gross  has  gathered  together  207  opera- 
tions :  Zesas  gives  the  results  of  162  cases,  and  provides  at  the 
same  time  a  short  description  of  each  case. 

Zesas,  who  lays  great  stress  upon  antiseptics,  divides  the 
operative  period  into  two  eras — the  pre-antiseptic  and  the  anti- 
septic. Of  his  162  cases,  31  belonged  to  the  former  period; 
and  only  one,  at  the  end,  was  successful.  In  the  antiseptic 
era  there  were  131  operations — 104  for  cancerous  stricture,  and 
27  for  cicatricial  stricture.  Of  the  first  class,  87  died  and  17 
recovered — a  mortality  of  nearly  84  per  cent.  Of  the  second 
class,  16  died  and  11  recovered — a  mortality  of  about  60  per 
cent.  The  chief  causes  of  death  were :  exhaustion  in  36, 
peritonitis  in  20,  and  pneumonia  in  10.  The  periods  of  dying 
*  Trans.  Amer.  Surg.  Association,  vol.  ii.,  p.  363.  t  Loc.  cit. 
24 


354  GASTROSTOMY. 

are  divided  as  follows :  under  24  hours,  17  cases ;  under 
30  hours,  69;  between  i  and  12  months,  19;  between  12  and 
18  months,  i.  So  far  as  I  know,  the  most  successful  operation 
for  cancerous  stricture  is  one  performed  by  Dr.  James  Murphy, 
of  Sunderland.  His  patient  lived  403  days  after  the  operation, 
which  was  not  performed  till  obstruction  was  complete.  * 

Gross  gives  for  his  207  cases  61  deaths  onl}^,  or  a  mortality 
of  29.47  per  cent.  At  the  date  of  the  last  reports,  he  reckons 
that  these  operations  had  prolonged  life  for  an  average  of  82 
days  in  each  case.  For  cancer,  167  operations  were  performed, 
with  49  deaths  (29.34  P^^  cent,  mortality) ;  for  cicatricial 
stricture,  37  operations,  with  11  deaths  (29.72  per  cent.). 
Peritonitis,  pneumonia,  and  shock,  were  the  chief  causes  of 
death.  This  shows  results  apparently  much  more  favourable 
than  Zesas  quoted.  Gross  adds  of  cancerous  stricture  :  "  Of 
the  entire  number,  117  died  in  one  month;  4  were  living,  but 
how  long  cannot  be  determined  ;  and  46  survived  longer  than 
one  month — the  average  duration  of  life,  after  the  stomach  was 
opened,  being  33  days."  Speaking  of  cicatricial  stricture,  he 
says :  "  Of  the  entire  number,  20  died  within  one  month, 
and  17  survived  upwards  of  one  month — the  average  duration 
of  life,  after  the  stomach  was  opened,  having  been  295  days." 

An  examination  of  these  figures,  apparently  irreconcilable, 
will  show  how  difficult  a  thing  it  is  to  say  what  is,  and  what  is 
not,  a  death  from  operation.  To  fix  an  arbitrary  period  up  to 
which  the  operation  is  said  to  cause  death,  and  beyond  which 
the  disease  is  blamed,  is  simply  impossible ;  and  nothing  short 
of  this  would  render  statistics  trustworthy.  We  are  dealing 
with  imponderable  quantities.  Death  from  peritonitis  at  the 
end  of  a  week  in  a  moderately  well-nourished  young  patient 
with  cicatricial  stricture,  is  a  very  different  thing  from  death 
in  the  same  wa}^  in  an  old  patient  in  the  last  stage  of  exhaustion 
with  cancerous  stricture.  They  cannot  be  classed  together  for 
comparison. 

Statistics  seem  to  prove  little  in  the  way  of  results,  beyond 
the  fact  that  the  operation  is  systematically  delayed  too  long. 
*  Brit.  Med.  Journ.,  Oct.  28,  18S8. 


APPRECIATION.  355 

It  would  probably  be  no  exaggeration  to  affirm  that,  at  the 
present  day,  a  skilled  surgeon  could  operate  on  suitable  cases 
with  a  mortality  under  lo  per  cent.  Looked  at  practically,  the 
question  is  something  like  this  :  What  is  best  for  the  patient — 
early  operation,  a  ten  per  cent,  risk,  a  certain  avoidance  of 
death  from  starvation,  and  a  probably  considerable  prolon- 
gation of  life  ;  late  operation,  and  a  risk  rising  up  to  or  even 
beyond  fifty  per  cent. ;  or  no  operation  at  all,  with  the  certainty 
of  death  from  starvation  if  he  escape  certain  accidents. 

The  answer  is  widely  different,  according  as  the  disease  is 
malignant  or  non-malignant.  In  the  case  of  simple  stricture, 
successful  gastrostomy  saves  life,  and  adds  indefinitely  to  the 
span  of  healthy  existence.  In  this  sense  the  operation  is  as 
justifiable  as  any  which  receives  the  sanction  of  the  profession. 
When  other  measures  fail,  gastrostomy  gives  the  only  chance  of 
life  :  if  it  saved  only  ten  per  cent,  of  the  cases,  it  would  still  be 
justifiable,  as  much  as  ligature  of  the  very  largest  arteries  if  the 
patient  is  bleeding  from  them.  I  conceive,  therefore,  that  in 
every  case  of  cicatricial  stricture  of  the  oesophagus,  as  soon  as 
it  becomes  evident  that  minor  measures  are  ceasing  to  be 
efficient,  we  ought  to  perform  gastrostomy.  And,  further,  the 
operation  ought  not  to  be  delayed  beyond  the  time  when  the 
health  begins  palpably  to  suffer.  If  the  necessity  for  operation 
becomes  apparent,  the  patient  ought  not  to  be  deprived  of  the 
best  chances  of  success. 

In  cancerous  stricture  the  case  is  very  different.  Here 
gastrostomy  is  a  procedure  of  the  nature  of  colotomy  for 
malignant  stricture  of  the  rectum,  intended  merely  to  prolong 
life  and  to  render  it  less  uncomfortable.  Theoretically,  it  ought 
to  have  a  smaller  mortality  than  simple  stricture.  While  gas- 
trostomy for  simple  stricture  would  be  justifiable  with  a  large 
death-rate,  the  same  operation  for  malignant  stricture  would  not 
be  recommended  if  the  mortality  were  excessive.  What,  in 
actual  figures,  would  constitute  an  excessive  mortality  it  is 
impossible  to  say.  Indeed,  to  lay  down  any  hard  and  fast  line 
up  to  which  the  proceeding  is  justifiable,  and  beyond  which  it 
is    not   justifiable,  would    be   absurd.     It   must   be  left  to  the 

24  * 


356  GASTROSTOMY. 

judgment  of  the  surgeon.  In  such  a  case,  I  am  of  opinion 
that  considerable  weight  ought  to  be  given  to  the  desires  of  the 
patient,  after  an  honest  and  impartial  statement  of  the  possible 
and  probable  results  have  been  put  before  him.  My  experience 
is,  that  he  elects  not  to  be  operated  upon.  If  he  can  swallow 
even  a  little,  he  is  loth  to  believe  that  he  will  not  improve,  and 
he  puts  off  operation  from  day  to  day,  till  it  is  too  late ;  when 
the  power  of  swallowing  has  passed,  and  he  is  being  fed  entirely 
on  enemas,  he  has  already  got  so  near  to  the  inevitable  end, 
that  he  desires  nothing  more  than  that  it  should  not  be  much 
longer  postponed.  In  some  the  love  of  life  is  strong,  and  it 
may  be  difficult  for  the  surgeon  to  withstand  entreaties  to 
operate  in  a  case  where  the  prospects  are  all  but  hopeless. 
To  dictate  advice  is  impossible  ;  the  action  of  the  surgeon  will 
follow  the  leadings  of  his  conscience. 

The  question  of  removal  of  the  cancerous  stricture  (oeso- 
phagectomy)  may  be  introduced  as  an  alternative.  Of  the  five 
cases  of  this  operation  collected  by  Gross,  to  which  Butlin-''  has 
added  a  sixth,  three  died  of  the  operation,  and  the  others  soon 
died  of  recurrence  of  the  disease.  Butlin  concludes,  in  my 
opinion,  rightly,  that  the  operation  has  at  present  no  locus  standi, 
and  that  there  is  little  prospect  of  our  being  able  to  perform  it 
except  in  very  exceptional  instances. 

It  is  necessary  to  state  that  certain  surgeons  of  repute 
consider  that  gastrostomy  ought  never  to  be  performed  for 
cancer  of  the  oesophagus.  Gunther  and  Gallard  consider  the 
existence  of  cancer  as  an  absolute  contra-indication.  Lagrangef 
thinks  the  operation  ought  to  be  limited  to  certain  favourable 
cases.  He  argues  that,  when  complete  obstruction  by  cancer 
has  taken  place,  the  neighbouring  viscera  will  have  been  in- 
volved— a  statement  which  is  manifestly  too  sweeping. 

The  operation  has  suffered  in  two  ways.  It  has  too  often 
been  performed  by  unskilled  operators,  and  it  has  been  delayed 
too  long  in  the  large  majority  of  instances.  A  fuller  knowledge 
of  the  conditions  surrounding  the  operation  will  no  doubt  partly 
remove  these  objections ;  more  judgment  will  be  exercised  in 
*  Op.  cit.,  p.  210.  t  Revue  de  Chirurgie,  1885,  No.  7. 


THE   OPERATION.  357 

the  selection  of  cases,  and  more  skill  will  be  exhibited  in  the 
technics  of  the  operation. 

For  syphilitic  disease  the  operation  has  been  performed  at 
least  twice,  in  neither  case  with  success ;  and  twice  for  obstruc- 
tion produced  by  enlarged  bronchial  glands,  with  one  success 
and  one  failure. 

In  cicatricial  stricture  in  children,  dilatation  is  particularly 
difficult,  and  operation  is  called  for  at  an  early  period.  The 
success,  too,  immediate  and  remote,  is  naturally  greater. 


THE    OPERATION. 

Any  preparatory  proceedings  will  depend  on  the  method 
selected  and  on  the  condition  of  the  patient.  It  simplifies  the 
operative  details  to  have  the  stomach  distended.  In  cases 
where  the  patient  can  swallow,  some  bland,  innocent  drink  may 
be  given  before  operation.  The  employment  of  any  of  the 
numerous  artificial  methods  of  dilating  the  stomach,  such  as 
may  be  used  in  gastrotomy,  is  not  advisable  in  this  operation, 
except  in  certain  cases  of  cicatricial  stricture.  The  operation 
must  be  done  with  as  little  worry  and  disturbance  to  the  patient 
as  possible,  and  quickly  as  well :  artificial  dilatation,  either 
before  or  during  anaesthesia,  is  objectionable  on  both  these 
grounds.  Besides,  the  advantage  of  it  is  doubtful.  We  desire 
to  place  the  sutures  in  the  stomach  wh?re  there  will  be  least 
traction,  and  this  may  not  be  where  the  dilated  stomach  pre- 
sents. If  the  stomach  is  full  at  the  operation,  it  will  be  empty 
very  soon  afterwards.  By  placing  the  sutures  when  the  stomach 
is  empt}',  we  see  and  know  the  worst  that  its  contraction  can  do. 
The  increased  difficulty  in  operating  refers  only  to  the  finding  of 
the  stomach  ;  and,  if  the  operator  has  that  amount  of  tactile 
skill  in  the  abdominal  cavity  which  he  ought  to  have,  this  diffi- 
culty is  very  small  indeed.  I  should  not,  therefore,  in  the 
slightest  degree  add  to  the  patient's  discomfort  by  trying  to 
dilate  the  stomach. 

Before  operation  it  will  be  wise  to  administer  a  specially 
stimulating  enema  containing  an  ounce  or  two  of  brandy. 


358  GASTROSTOMY. 

The  operation  is  conveniently  described  under  three  heads  : 
(i)  Making  the  parietal  incision  ;  (2)  Suturing  the  stomach-wall 
to  the  opening;  and  (3)  Opening  the  stomach. 

The  Parietal  Incision. — Many  forms  of  incision  have  been 
recommended  and  adopted.  Sedillot  used  a  cross  incision 
belovv^  the  xiphoid  process.  Fenger's  incision,  next  introduced, 
made  parallel,  and  near,  to  the  left  costal  margins,  is  the  one 
now  most  generall}^  used.  Sydney  Jones  made  an  almost  ver- 
tical incision  in  a  line  drawn  from  the  left  nipple  to  the  spine  of 
the  pubes.  Kiister  incised  the  linea  alba.  Maury  used  a  curved 
incision,  with  its  convexity  towards  the  middle  line.  Cooper 
Forster  employed  a  vertical  incision  through  the  top  of  the 
linea  semilunaris,  and  manj^  English  surgeons  have  adopted  his 
plan.  Howse  recommends  a  vertical  incision  through  the  outer 
edge  of  the  rectus — a  method  which  has  the  advantage  of 
surrounding  the  fistula  by  muscular  fibres,  which  in  their  con- 
traction tend  to  close  it.  Girard^''  has  suggested  a  method  of 
increasing  the  sphincter  action  of  the  rectus  by  isolating  two 
bundles  of  its  fibres  as  thick  as  fingers,  and  crossing  them  so  as 
to  form  a  double  loop  around  the  opening  in  the  stomach. 

The  actual  line  of  incision  followed  would  not  seem  to  be  of 
supreme  importance.  It  must  be  as  short  as  possible.  A  long 
incision  unnecessarily  weakens  the  abdominal  wall,  and  has  a 
tendency  to  permit  subsequent  protrusion  of  the  stomach.  It 
must  not  be  too  close  to  the  ribs,  as  their  movements  during 
respiration  disturb  the  wound  and  weaken  or  tear  or  stretch  the 
peritoneal  adhesions.  Unless  at  least  an  inch  of  space  is  left 
between  the  edge  of  the  wound  and  the  costal  margin,  the  upper 
lip  of  the  wound  protrudes,  and  the  lower  lip  is  drawn  inwards. 
This  last  objection  does  not  apply  to  the  vertical  incision. 
Then,  again,  it  must  be  so  placed  that  the  margin  of  the  left 
lobe  of  the  liver  does  not  press  upon  the  sutures  fixing  the 
stomach  to  the  abdominal  wall.  Now,  the  position  of  the 
margin  of  the  left  lobe  varies.  It  may  lie  as  high  as  the  lower 
edge  of  the  xiphoid  process,  or  it  may  descend  as  low  as  the  tip 
*  Wiener  Med.  Presse,  1888,  No.  28. 


THE  PARIETAL   INCISION. 


359 


of  the  cartilage  of  the  ninth  rib.  We  may  expect  to  find  it 
lower  than  normal,  as  it  falls  downward  on  account  of  the 
hollow  viscera  being  empty.  In  a  case  on  which  I  operated  the 
left  lobe  was  greatly  enlarged  and  its  margin  depressed  through 
the  presence  of  a  shrivelled  hydatid  cyst  in  the  right  lobe. 

The  site  of  election  must  be  as  high  up  as  possible,  to  avoid 
traction  on  the  stomach  ;  and  it  must  be  low  enough  down  to 
be  well  clear  of  the  margins  of  the  ribs  and  the  liver.  The 
situation  is  better  decided  by  palpation  and  percussion,  than  by 
anatomical  landmarks.  The  retiring  angle  between  the  ribs  and 
the  edge  of  the  liver  is  marked  out,  and  a  site  is  fixed  upon  at 

least  an  inch  distant  from 
both.  At  this  point  the 
fistula  should  be  estab- 
lished. The  incision, 
therefore,  ought  to  extend 
equally  on  both  sides  of 
this  point  —  say,  three- 
quarters  of  an  inch  on 
each  side  of  it.  (Fig.  47.) 
The  vertical  incision 
has  man}'  advantages, 
more  especially  after  the 
fistula  has  been  estab- 
lished. But  the  oblique 
incision  is  on  the  whole, 
perhaps,  the  better,  and 
more  particularly  because  it  gives  greater  freedom  during  opera- 
tion. Tillaux  recommends,  as  an  anatomical  landmark,  the  tip  of 
the  cartilage  of  the  ninth  rib,  which  is  separated  a  little  way  from 
the  fixed  cartilage  above  it,  and  can  be  diagnosed  by  the  sensa- 
tion of  grating  which  is  felt  when  it  is  rubbed  on  this  cartilage 
Landmarks  taken  from  the  linea  semilunaris  vary  too  much  to 
be  trustworthy.  If  the  edge  of  the  liver  cannot  be  determined 
by  palpation  or  percussion— a  rare  event — then  the  tip  of  the 
ninth  rib-cartilage  is,  perhaps,  the  best  landmark.  But  its 
position  I  have  found,  from  repeated  observations,  to  vary  also. 


Fig.  47. 

Diagram  to  sfiom  Site  of  Fistula  in 
Gastrostomy. 

The  opening  is  made  at  a,  b,  or  c,  according  as  the 
liver  margin  corresponds  to  the  lines  i,  2,  or  3. 


360  GASTROSTOMY. 

Frequently  the  line  of  incision  will  be  found  to  lie  equally  on 
both  sides  of  the  linea  semilunaris  ;  more  often,  it  will  be  on  the 
outside  of  it.  Occasionally  it  will  be  entirel}'  to  the  inside  of 
this  line.  The  direction  of  the  incision  will  always  be  parallel 
to  the  edges  of  the  ribs,  distant  from  them  three-quarters  of  an 
inch,  or  a  little  more,  if  the  abdominal  walls  are  thick.  It  need 
not  be  longer  than  an  inch  and  a  half,  or  at  most  two  inches — 
this  is  sufficient  to  admit  two  fingers. 

The  skin  and  fascia  being  divided,  the  muscles  are  severed 
by  successive  cuts  of  the  knife,  pressure-forceps  being  placed 
on  the  bleeding  points.  The  external  oblique,  thick  and  fleshy, 
will  be  divided  almost  transversely  to  the  direction  of  its  fibres. 
The  thin  fibres  of  the  internal  oblique  lie  nearly  parallel  with 
the  direction  of  the  wound,  and  they  may  be  separated  with 
the  handle  of  the  knife.  The  fibres  of  the  transversalis  will  be 
cut  transversely.  If  the  linea  semilunaris  is  crossed,  the  fibres 
of  the  rectus  are  cut  obliquely.  From  a  surgical  point  of  view, 
it  is  a  matter  of  no  moment  what  fibres  are  cut  through,  nor 
how  they  are  cut.  Union  is  equally  certain,  and  the  difficulties 
are  insignificant.  When  the  sub-peritoneal  fat  is  reached,  it  is 
pinched  up  with  catch-forceps  and  pulled  to  the  surface.  A 
second  pair  of  forceps  is  placed  below  the  first,  which  is  handed 
to  an  assistant,  and  the  raised  fold  of  peritoneum  gently  sawed 
through  by  the  blade  of  the  knife  held  horizontally. 

The  peritoneum  being  divided  on  the  finger  to  the  length  of 
the  wound,  two  retractors  draw  the  edges  of  the  incision  apart, 
so  as  to  permit  a  view  of  the  presenting  organ.  If  the  stomach 
is  distended,  it  may  present  at  the  wound,  and  this  visible 
portion  may  at  once  be  selected  for  the  placing  of  the  fixation 
sutures.  Theoretical  considerations  as  to  the  advisability  of 
having  the  opening  in  a  certain  position  of  the  stomach,  pre- 
ferably near  the  cardia  and  the  lesser  curvature,  are  of  small 
weight,  as  compared  with  the  importance  of  avoiding  all  trac- 
tion on  the  stomach-wall. 

In  most  cases,  however,  the  stomach  will  be  contracted,  and 
situated  high  up  under  the  diaphragm,  while  the  colon  or  the 
omentum  presents  at  the  wound.     It  is  quite  possible  to  mistake 


FIXATION   OF  THE  STOMACH.  361 

the  colon  for  the  stomach  :  more  than  once  the  colon  has  been 
opened.  To  find  the  stomach,  we  may  either  pull  it  down  by 
dragging  on  the  omentum  and  the  colon,  or  we  may  follow  the 
suggestion  of  Legond,  highly  recommended  by  Farabeuf,  and 
use  the  under  surface  of  the  liver  as  a  guide.  The  fingers  are 
carried  under  the  left  lobe  of  the  liver  till  they  reach  the  ver- 
tebral column  :  they  are  then  moved  to  the  left,  close  to  the 
diaphragm,  when  the  lesser  curvature  will  be  felt.  The  stomach 
is  always  the  highest  of  the  hollow  viscera.  When  recognised, 
a  fold  of  its  anterior  wall  is  pinched  up  between  the  two  fingers 
and  pulled  to  the  surface  of  the  wound.  The  part  which  seems 
best  to  fulfil  the  double  purpose  of  avoiding  traction  and  pro- 
viding a  suitable  spot  for  forming  a  fistula  is  then  fixed  upon, 
and  the  next  step  proceeded  with. 

Fixation  of  the  Stomach. — The  mode  of  fixing  the  wall  of  the 
stomach  to  the  parietes  will  depend  on  whether  the  opening  is 
to  be  made  at  once,  or  postponed  for  several  days  until  adhe- 
sions have  formed.  The  usual  practice  is  now,  in  all  cases,  to 
follow  the  latter  plan.  Where  the  patient  can  afford  to  wait, 
this  is  no  doubt  the  better  method  ;  but  it  is  by  no  means  cer- 
tain that  it  is  always  the  better  method.  A  few  continental 
surgeons  of  the  highest  repute  advocate  immediate  opening  of 
the  stomach.  They  maintain  that,  the  stomach  being  in  most 
cases  empty,  the  danger  of  extravasation  is  exaggerated ;  and 
that,  if  the  sutures  are  properly  placed,  the  danger  of  subse- 
quent escape  of  fluids  into  the  cavity  is  very  small.  Zesas  and 
others  have  pointed  out  the  great  danger  of  withholding  food 
from  a  half- starved  patient  upon  whom  has  just  been  put  the 
additional  strain  of  a  severe  surgical  operation.  Exhaustion  is 
the  most  common  cause  of  death  ;  and  exhaustion  is  best  com- 
bated by  stomach  feeding.  The  low  vitality  of  the  patient  is 
against  the  rapid  formation  of  strong  adhesions.  Kocher  points 
out  the  risks  of  traction  on  an  empty  stomach,  through  inter- 
ference with  its  circulation :  this  risk  is  obviated  by  immediate 
feeding. 

I  take  it  that  we  cannot  lay  down  a  rule  which  will  apply  to 


362  GASTROSTOMY. 

all  cases  :  the  mode  of  opening,  and  therefore  of  suturing,  must 
be  decided  for  each  case.  The  advantage  of  having  even  a  little 
fresh  lymph  between  the  serous  surfaces  is  evident  :  this  can  be 
secured  by  waiting  for  a  few  hours.  In  the  worst  cases,  we  can 
spare  ten  or  twenty-four  hours :  this  time  may  nearly  always  be 
given  to  the  formation  of  adhesions.  In  cases  where  the  power 
of  swallowing  exists,  or  where  weakness  is  not  excessive,  or 
where  (as  sometimes  happens)  power  to  swallow  returns  after 
operation,  we  may  wait  as  long  as  possible,  and  open  the 
stomach  only  when  the  strength  is  beginning  to  fail.  We  must 
not  let  the  patient  die  while  we  wait  for  surgical  perfection  in 
the  wound  ;  nor,  on  the  other  hand,  need  we  be  in  haste  to 
establish  the  fistula  if  the  patient's  strength  holds  out  well. 

The  proceeding  to  be  adopted,  if  we  intend  to  postpone  the 
opening  of  the  stomach  for  a  week  or  so,  may  be  much  simpler 
than  if  we  desire  to  make  immediate  opening.  Sedillot,  in  his 
second  case,  sought  to  cause  adhesion  of  the  stomach  to  the 
parietes,  and  at  the  same  time  to  make  the  opening  in  the 
stomach  by  necrosis,  by  attaching  a  forceps  to  the  stomach  and 
leaving  it  there.  This  plan  he  did  not  like,  and  he  proposed  to 
transfix  the  stomach-wall  by  an  ivory  pin.  FoUowmg  a  sugges- 
tion of  Macnamara,  Boyce  Barrow  and  others  have  adopted 
this  plan,  employing  harelip  pins  ;  and  there  is  probably  none 
better.  Other  plans  of  forming  adhesions,  by  caustics,  acupunc- 
ture and  rows  of  needles,  have  been  recommended  and  adopted; 
but  none  of  them  seem  trustworthy.  Howse  is  said  to  use 
clamp  forceps  padded  with  India-rubber;  and  his  results  are 
excellent. 

In  cases,  therefore,  where  the  opening  of  the  stomach  is  to 
be  postponed  for  some  days,  sutures  need  not  be  inserted. 
Mere  apposition  of  the  surfaces  will  result  in  the  formation  of 
sufficiently  strong  adhesions.  To  secure  this  end,  the  use  of  two 
thick  harelip  pins  is  by  far  the  simplest  plan,  and  perfectly  satis- 
factory. The  points  of  the  pins  should  be  rounded  and  smooth, 
and  not  cutting.  They  are  carefully  inserted  under  the  serous 
and  muscular  coats  of  the  stomach,  in  lines  transversely  to  the 
direction   of  the  wound;    and   they  enclose   a   square   area  of 


FIXATION   OF  THE  STOMACH.  363 

stomach-wall,  whose  sides  measure  about  three-quarters  of  an 
inch.  In  the  centre  of  this  square  the  opening  is  subsequently  to 
be  made.  The  ends  of  the  pins  are  stuck  into  pieces  of  India- 
rubber,  to  prevent  them  from  chafing  the  skin  on  which  they 
rest.  If  the  abdominal  walls  are  thick,  the  pins  may  be  bent 
downwards  in  the  middle  ;  in  fact,  a  little  downward  curve  will 
always  be  advantageous.  If  the  pins  are  not  removed,  it  may  be 
possible  to  open  the  stomach  after  four  or  five  days,  so  perfect 
is  the  apposition  which  they  give.  Macnamara  has  supplemented 
this  plan  by  the  insertion  of  a  piece  of  thick  silver  wire  into  a 
fold  of  the  stomach,  which  was  fixed  to  the  skin  of  the  chest. 

If  it  is  decided  to  open  the  stomach  within  three  or  four  days, 
it  will  be  wise  to  make  use  of  sutures,  Chavasse,  in  a  successful 
case,  used  only  four  sutures.  Two  or  three  sutures  in  addition  to 
pins  would  be  as  good  a  plan  as  any  to  adopt,  if  the  stomach  is  to 
be  opened  between  the  third  and  the  fifth  day.  For  late  opening 
the  suturing  has  been  overdone.  In  one  case  I  used  a  deep 
continuous  silver  suture  and  four  superficial  silk  sutures,  with 
success.  In  another,  four  deep  and  four  superficial  sutures  gave 
perfect  apposition.  Many  similar  plans  have  been  successfully 
used — most  of  them,  like  mine,  erring  on  the  side  of  doing  too 
much. 

When  the  stomach  has  to  be  opened  at  once,  or  after  a  few 
hours,  the  method  of  suturing  must  be  more  elaborate.  It  must 
secure  accurate  apposition  from  the  beginning  all  around,  with- 
out inflicting  too  much  injury  on  the  stomach,  and  without 
involving  too  large  an  area  of  its  walls.  Many  plans  are  in 
vogue :  the  following  is,  perhaps,  as  good  as  any.  By  it, 
stomach-wall  is  kept  in  accurate  apposition  with  parietal 
peritoneum  in  a  continuous  circle,  and  not  at  interrupted  points. 
Firstly,  following  Bryant's  excellent  suggestion,  insert  two  loops 
of  silver  wire  near  the  spot  where  the  opening  is  to  be  made. 
By  these  the  stomach  is  manipulated  during  the  process  of 
suturing,  and  they  serve  to  fix  it  when  the  opening  is  made. 
Then,  with  a  round  needle  threaded  with  thick  soft  silk  about  a 
foot  long,  pass  a  continuous  suture,  in  a  circle  of  about  two 
inches  in  diameter,  under  the  peritoneal  and  muscular  coats  of 


364 


GASTROSTOMY. 


the  stomach.  At  every  third  quarter  of  an  inch  in  the  circle, 
the  needle  is  taken  out  and  re-inserted ;  so  that  six  or  eight  free 
loops,  about  an  inch  and  a  half  in  length,  are  left  protruding  on 
the  serous  surface.  (Fig.  48.)  Then,  at  corresponding  situations 
in  the  abdominal  wall,  a  handled  needle  with  a  recurved  hook 
instead  of  an  eye  (Fig.  50)  is  pushed  through,  and  catches  up 

the  loops  one  after  the  other. 

As     each    loop    is    drawn 

through,   a  piece  of  rubber 

tubing   is  slipped  under  it. 

The  loops  are  pulled  with 

moderate  tightness  over  the 

rubber  tubing  from  each  end 

of  the  incision.    Finally,  the 

ends  of  the 

silver     su-  "V 

tures    are 

hooked  un- 

d  e  r     the 

tubing,  and 

serve     to 

keep     the 

exposed 

portion     of 

stomach 

well  up   in 

the  gaping 

w  o  u  n  d  . 

(Fig.  49.) 
A  suture  at 
each  end  of 
the  wound 
may  be 
necessary. 

It  will 
be  seen 
that  this 


Fig.  48. 


Fig.  49. 

Figs.  48  &  49. — Diagrams  to  show  Fixation 

of  Stomach  to  Parietes  for 

Immediate  Opening  in  Gastrostomy. 


Fig:  50. 
Eyeless  Needle 


for  Inserting   Sutures 

as  it  is  withdrawn. 

One -third  size. 


OPENING    THE  STOMACH.  365 

mode  of  fixing  the  stomach  is  easih'  and  rapidly  carried  out : 
that  it  provides  accurate  apposition  under  elastic  pressure  ;  and 
that  it  does  not  draw  the  stomach  too  much  outwards,  and  so 
increase  the  risk  of  having  a  dribbling  fistula  to  deal  with. 

Opening  the  Stomach. — This  is  a  very  simple  proceeding.  It 
is  quite  painless,  and  requires  no  anaesthetic.  Consequentl}-,  as 
adhesive  material  is  very  rapidly  thrown  out  between  serous 
surfaces, — they  may  be  glued  together  in  four  or  five  hours, — 
the  opening  need  not  be  made  till  the  patient  has  full}'  recovered 
from  the  anaesthetic,  when  also  the  stomach  is  more  likely  to  be 
tolerant  of  food. 

It  is  important  to  follow  Bryant's  wise  advice,  and  make  the 
opening  as  small  as  possible,  to  prevent  dribbling  of  the  gastric 
contents.  The  opening  may  be  made  by  gentl}'^  inserting  the 
fine  point  of  a  curved  bistoury  under  the  muscular  and  serous 
coats,  and  cutting  outwards.  Through  this  minute  opening, 
a  Lister's  sinus  forceps  is  insinuated  through  the  mucosa,  its 
blades  are  separated,  and  a  small  French  gum-elastic  catheter 
is  passed  into  the  stomach  between  them.  The  divergent  blades 
of  the  sinus  forceps  pull  the  stomach  outwards  while  the 
catether  is  being  passed  inwards,  and  the  whole  operation  is 
easily  concluded  without  any  disturbance  of  parts. 

Fluid  food  in  small  quantity— about  six  ounces  of  warm 
peptonised  milk  is  perhaps  the  best — is  slowly  passed  into  the 
stomach  through  the  catheter.  After  feeding,  the  catheter  may 
either  be  removed  or  left  in  place,  as  seems  most  desirable. 
Both  plans  have  their  advantages  and  disadvantages.  If  it  is 
removed,  the  small  opening  is  completely  closed  by  the  mucous 
membrane  acting  as  a  plug  ;  but  a  little  difficulty  may  be 
experienced  in  re-introducing  it :  if  it  is  left,  this  difficult}'  is 
obviated  ;  but  fluid  is  liable  to  find  its  way  along  the  side  of  the 
catheter.  Such  fluid,  acid  gastric  juice,  has  an  irritating  effect 
on  the  wound,  seeming  to  disolve  up  the  recent  and  delicate 
adhesions.  To  collect  any  juice  that  may  escape,  the  wound 
should  be  kept  covered  by  some  highly  absorbent  unirritating 
material,  which  is  to  be  frequently  changed. 


366  GASTROSTOMY. 

When  the  opening  is  made  a  few  days  after  operation,  the 
procedure  is  compHcated  by  the  presence  of  a  layer  of  lymph 
filling  up  the  cavity  between  the  lips  of  the  wound.  This  may 
bleed  if  it  is  removed  by  forceps.  In  this  case,  it  is  not  so  easy 
to  judge  of  the  depth  of  the  puncture  to  be  made  by  the  knife, 
and  more  disturbance  of  the  parts  may  be  caused  than  in  imme- 
diate opening.  But  this  matters  little,  for  adhesions  are  likely 
to  be  firm.  And  if  the  plan  of  fixation  by  pins  be  adopted,  the 
opening  is  a  very  simple  affair.  The  insertion  of  a  catheter  is 
conducted  as  above  recommended ;  and  it  may  be  left  in,  with  a 
plug  to  close  it.  It  is  fixed  by  a  thread  to  pieces  of  strapping 
on  the  skin  of  the  abdomen. 

When  the  opening  of  the  stomach  is  delayed,  and  the 
patient  cannot  swallow,  feeding  by  the  rectum  must  be  instituted. 
This  is  a  proceeding  of  great  importance,  requiring  care  both  in 
the  preparing  and  in  the  administering  of  the  enema.  Rectal 
feeding  has  received  much  attention  of  recent  years,  and  many 
valuable  preparations  may  be  had.  I  believe  that  we  do  not 
always  remember,  in  rectal  feeding,  that  a  certain  quantity  of 
fluid  is  an  essential  ingredient  of  all  foods.  The  concentrated 
meat  capsules  and  suppositories  now  frequently  used  should  be 
supplemented  by  an  injection  once  or  twice  daily  of  a  pint  of 
tepid  water.  A  good  enema  for  such  cases  I  have  found  to  be 
the  following :  an  egg  beaten  up  in  ten  ounces  of  milk,  with  two 
or  three  teaspoonfuls  of  meat  jelly,  peptonised  in  the  ordinary 
way,  and  administered  warm,  with  or  without  the  addition  of 
brandy,  every  five  or  six  hours.  If  the  enema  is  passed  in  very 
slowly,  it  will  usually  be  retained  without  difficulty.  A  large 
enema  of  tepid  water  to  cleanse  the  rectum  is  necessary  every 
day,  or  ever}^  other  day.  If  some  of  it  is  absorbed,  it  will  do 
good  :  starvation  is  robbed  of  half  its  terrors  if  plenty  of  fluid  is 
given.  Zesas  and  others  who  have  spoken  of  nourishing  enemas 
in  such  cases  are  inclined  to  put  very  little  value  upon  them. 
Under  the  best  form  of  rectal  alimentation  yet  devised,  the 
patient  steadily  and  surely  loses  ground.  But  the  opinion  that 
they  help,  if  they  are  not  all-sufficient,  is  too  general  to  be 
delusive.     In  every  case,  rectal  feeding  must    be   used    where 


AFTER-TREATMENT.  367 

feeding  by  the  mouth  is  impossible  ;  onl}'  we  must  remember 
that  it  is  at  best  an  inefficient  substitute  for  feeding  by  the 
stomach,  and  that  opening  must  not  be  unduly  delayed. 

The  mode  of  feeding  by  the  fistula  is  of  some  importance. 
The  food  must  at  first  be  small  in  quantity,  and  of  a  nature  to 
be  readily  absorbed,  so  as  to  cause  the  least  possible  physical 
and  physiological  disturbance.  Peptonised  milk,  or  beef  tea,  or 
beef  peptonoids,  are  readily  absorbed  and  nourishing.  Starchy 
and  fatty  foods,  which  undergo  digestion  chiefl}'  in  the  intestine, 
maj''  be  administered  alternately  with  the  more  stimulating 
fleshy  materials.  "  Often  and  little  "  has  been  the  advice  given  ; 
but,  as  previously  remarked,  not  too  often  nor  too  little.  Too 
frequent  feeding  may  irritate  the  stomach  as  well  as  the  fistula, 
and  too  little  will  fail  to  support  the  patient's  strength.  Half 
a  pint,  slowly  administered  every  four  hours,  would  be  an 
average  quantity  and  frequency. 

All  foods  introduced  into  the  stomach  should  be  of  the 
temperature  of  the  body.  When  the  patient  has  got  over  the 
dangers  of  the  operation,  the  food  may  be  administered  only  at 
the  ordinary  meal  times.  It  has  been  recommended  that  solid 
food  should  be  masticated  before  being  passed  into  the  funnel 
which  leads  to  the  stomach.  If  there  is  a  sympathy  between 
the  mouth  and  the  stomach,  causing  the  stomach  to  undergo 
certain  physiological  changes  preparatory  to  the  reception  of 
food,  this  recommendation  has  a  meaning  beyond  the  gustatory. 
Cases  are  recorded  where,  by  the  help  of  ingenious  contrivances, 
the  patient  has  sat  at  table,  masticated  food,  and  passed  it  into 
the  stomach-tube  without  shocking  the  susceptibilities  of  his 
companions.  The  patient  will  soon  learn  what  apparatus  is 
best  for  feeding ;  and  how,  in  the  intervals,  the  fistula  may  be 
most  perfectly  kept  closed  and  protected.  Feeding  by  gravi- 
tation is  usually  the  mode  selected,  and  a  pad  of  clean  linen 
will,  in  most  cases,  efficiently  guard  the  wound. 


Gastrotomy, 

Gastrotomy  {r'/aa-Ti'jp — stomach,  and  to/i>/ — incision)  is  here 
used  in  the  limited  sense  of  meaning  the  operation  of  making 
an  incision  into  the  stomach,  and  more  particularly  with  the 
view  of  removing  foreign  bodies  lodged  in  that  viscus.  Gas- 
trotomy may  have  to  be  performed  for  other  purposes,  as  for 
dilatation  of  the  pylorus  or  the  oesophagus,  or  for  the  removal 
of  foreign  bodies  in  the  gullet ;  but  in  these  cases  the  operation 
is  subsidiary.  As  a  synonym  for  abdominal  section,  the  Avord 
Gastrotomy  is  in  frequent  use  at  the  present  time ;  in  this  sense 
its  employment  is  confusing. 


GASTROTOMY    FOR    THE    REMOVAL   OF    FOREIGN    BODIES    IN    THE 

STOMACH. 

This  is  a  very  old  operation.  One  Crolius  is  said  to  have 
removed  a  knife  from  the  stomach  in  1602,  and  Guenther  is 
credited  with  a  similar  operation  in  161 3.  In  1635  Shoval* 
successfully  removed  a  knife  six  inches  long,  and  in  the  same 
year  Schwaben  had  a  like  success.  Considering  the  early  and 
striking  success  of  gastrotomy,  and  the  undoubted  frequency  of 
the  necessity  for  it,  it  is  remarkable  that  the  operation  was 
performed  so  few  times  in  the  following  century.  Successful 
cases  are  reported  by  Hubner  in  1720,  by  Cayroches  in  1829,  by 
Bell  in  i860,  by  Labbe  in  1874,  ^-nd  by  others. |  It  is  perhaps 
even  more  remarkable  that  in  the  modern  era  of  abdominal 
surgery  the  operation  should  have  been  so  rarely  performed. 
Gross§  quotes  only  twenty  cases,  three  of  which  were  fatal. 
The   more   accurate   tables   of  Credei]   and   Richardsonli    and 

*  Chelius's  Surgeyy,  vol  ii.,  p.  391         t  Ht^vin,  Mem.  de  I'Acad,  de  Chir.  de  Par. 

\  See  Poulet,  Foreign  Bodies  in  Surgical  Practice,  vol.  i.,  p.  162. 

g  Trans.  Amer.  Surg.  Assoc,  vol.  ii.       ||  Arch.  f.  klin.  Chir.,  XXXIII.,  iii. 

IT  Boston  Med.  and  Surg.  Journ.,  Dec.  i6th,  1886. 


INDICATIONS  FOR   OPERATION.  369 

Bernays,*  which  exclude  all  doubtful  or  ill- authenticated  cases, 
reduced  the  number  to  13  or  possibly  14.  All  recovered  save 
two,  and  in  these  were  specially  troublesome  complications. 
There  can  be  no  doubt,  therefore,  that  gastrotomy  is  not  a 
dangerous  operation  :  under  modern  rules,  it  ought  not  to  have 
a  death-rate  of  more  than  eight  or  ten  per  cent. 

Indications  for  Operation. — The  conditions  pointing  to  operation 
are  twofold  :  (i)  the  presence  of  a  foreign  body  in  the  stomach, 
of  such  a  nature  that  we  know  it  cannot  be  passed  through  the 
intestines,  or  can  be  passed  only  at  great  risk ;  and  (2)  the 
existence  of  serious  and  urgent  symptoms  in  the  patient. 

The  great  majority  of  foreign  bodies  swallowed  pass  through 
the  pylorus,  and  are  voided  in  the  stools.  It  is  a  common  state- 
ment that  anything  which  passes  the  cardiac  opening  will  pass 
the  pyloric.  And  so  it  will,  as  far  as  the  smallest  diameter  of 
the  body  is  concerned ;  but  where  long  bodies  are  swallowed, 
such  as  knives,  spoons,  forks,  pencils,  bars  of  lead,  or,  as  in 
Fournier's  case,  the  hoop  of  a  barrel  fifteen  inches  long,  we  can 
scarcely  expect  that  they  will  be  passed  through  the  pylorus 
and  along  the  duodenum  and  the  numerous  coils  of  small  intes- 
tine. As  a  matter  of  fact,  long  bodies  rarely  escape  from  the 
stomach  at  all. 

Aggregations  of  small  foreign  bodies  require  removal,  as 
much  as  long  or  large  single  bodies.  They  may  become  glued 
together  by  mucus,  and  form  a  mass  whose  diameter  is  con- 
siderably greater  than  that  of  the  pyloric  orifice.  Thornton  f 
and  Schonborn  I  have  successfully  removed  large  masses  of  hair 
swallowed  by  their  patients. 

Apart  from  the  remote  risk  attending  the  prolonged  presence 
of  a  foreign  body  in  the  stomach,  the  subjective  condition  of  the 
patient  may  be  such  as  to  demand  operation.  Tlie  patient  is 
constantly  nauseated ;  he  has  an  indefinable  sensation  of 
distress  and  anxiet}'  referred  to  the  pit  of  the  stomach  ;  he 
complains  of  severe  shifting  pains  in  various  situations,  which 

*  Phila.  Med.  News,  Jan.  ist,  1887.        t  Lancet,  Jan.  9th,  1886. 

J  Langenbeck's  Archiv,,  1883,  vol.  xxix.,  p.  609. 

25 


370  GASTROTOMY. 

are  sometimes  distracting  (in  at  least  one  case  they  drove  the 
sufferer  to  suicide) ;  and  his  combined  sufferings  often  render 
hfe  a  prolonged  agony.  In  other  cases  the  symptoms  are  less 
urgent,  but  they  are  always  more  or  less  distressing.  Frequently 
the  ingestion  of  food  relieves  the  pain ;  sometimes  it  aggravates 
it.  The  patient  occasionally  finds  relief  in  special  postures, 
and  constantly  assumes  them.  The  slightest  movement  may 
aggravate  the  pain  ;  the  patient  may  have  to  tread  with 
slowness  and  difficult}^,  and  his  breathing  may  be  performed 
superficially  or  with  effort.  Soon  the  health  fails  ;  the  patient 
becomes  pale,  thin  and  worn  ;  he  becomes  liable  to  attacks  of 
syncope,  or  even  convulsions  ;  vomiting  sets  in,  sometimes  with 
bleeding ;  wasting  goes  on  to  extreme  degrees,  and  death  takes 
place  in  the  last  stage  of  exhaustion. 

Local  conditions  demanding  operation  may  exist.  These 
are  produced  when  the  foreign  body  shows  signs  of  perforating 
the  walls  of  the  stomach,  either  immediately  by  cutting  them 
through,  or  gradually  by  ulceration  and  the  formation  of  abscess. 
Richardson '•'  has  collected  ii  such  cases  occurring  between  1602 
and  1882,  the  foreign  body  in  each  case  escaping  either  spon- 
taneously or  after  a  simple  incision  ;  and  only  one  of  these  cases 
died.  Perforation  into  the  peritoneum,  if  untreated,  is  certainly 
fatal.  The  risks  of  perforation  through  the  parietes  when  the 
stomach  becomes  adherent  to  them  are  evidently  not  so  great, 
but  they  are  sufficient  to  demand  operation.  Perforation  in 
other  directions — towards  spleen,  liver,  lung,  or  heart— must  be 
reckoned  among  the  terminal  casualties. 


THE    OPERATION. 

To  facilitate  operation,  various  plans  of  distending  the 
stomach  have  been  suggested.  Felizet  of  Paris  f  utilised  the 
vapour  of  ether  for  this  purpose,  m  an  operation  for  the  removal 
of  a  spoon.  A  piece  of  rubber  tubing  was  passed  into  the 
stomach  ;  the  outer  extremity  of  the  tube  was  bifurcated — one 
of  the  ends  communicating  with  a  funnel,  the  other  with  an  ether 
*  Loc.  cit.         t  Lancet,  vol.  ii.,  1882. 


THE   OPERATION.  371 

reservoir.  The  stomach  was  first  washed  out  with  a  solution 
of  bicarbonate  of  soda,  poured  in  through  the  funnel.  The 
ordinary  incision  was  then  made ;  when  it  was  concluded,  the 
ether  reservoir  was  placed  in  hot  water,  and  the  vapour,  passing 
along  the  tube  into  the  stomach,  distended  it  and  forced  it 
through  the  wound.  Felizet,  while  the  stomach  was  distended, 
sutured  it  to  the  wound  before  removing  a  spoon,  and  a  gastric 
fistula  was  left,  Schonborn,*  in  a  case  of  gastrostomy,  made 
use  of  a  bladder  attached  to  the  end  of  a  hollow  sound,  which 
he  distended  by  blowing.  Jacobi  f  and  Fowler  I  have  caused 
distension  by  pouring  into  the  stomach  measured  quantities  of 
acid  and  bicarbonate  of  soda.  Other  methods  have  been  used 
or  recommended. 

It  is  very  doubtful  if  the  advantages  of  distending  the 
stomach  counterbalance  the  disadvantages.  The  advantages 
are,  increased  facility  in  finding  the  stomach,  and  the  com- 
paratively small  size  of  the  opening  made  while  the  walls  are 
stretched.  The  chief  disadvantages  are,  the  trouble  to  the 
patient  connected  with  the  process  of  distension,  the  difficulty 
in  preventing  the  distending  agent  from  coming  into  contact 
with  the  peritoneum  (even  ether  is  not  innocuous),  and  the 
increased  difficulty  of  finding  the  foreign  body  in  a  distended 
cavity.  Billroth,  in  one  case,  found  this  last  difficulty  a  very 
troublesome  one  to  overcome.  The  exigencies  of  the  case  would 
probably  be  met  by  a  prior  cleansing  of  the  stomach  with  a 
dilute  solution  of  bicarbonate  of  soda.  There  is  no  objection 
to  the  patient's  swallowing,  just  before  operation,  eight  or  ten 
ounces  of  some  innocuous  fluid  ;  this  amount  will  be  quite  suffi- 
cient to  throw  the  stomach  into  prominence,  while  it  is  not  too 
large  to  be  collected  in  sponges  should  it  escape.  On  the  whole, 
perhaps,  it  is  best  to  operate  upon  an  empty  stomach,  which 
has  been  previously  cleansed  by  an  alkaline  solution. 

The  site  of  the  incision  is  not  of  so  much  importance  as  in 
gastrostomy.     It  may  be  higher  up  ;  if  the  liver  is  in  the  way,  it 

*  Langenbeck's /irc/(/i;.,  xxii.,  p.  500. 

t  New  York  Med.  Joiirn.,  1874,  vol.  xx.,  p.  142. 

I  Ann.  Anat.  and  Surg.,  vol.  vi.,  p.  27.     Brooklyn,  1882. 

25  * 


372  GASTROTOMY. 

can  easily  be  kept  back  by  a  retractor.  No  advantage  is  gained 
by  getting  close  to  the  ribs  ;  the  flexibility  of  the  parietes,  which 
is  useful  in  permitting  manipulation  and  the  introduction  of 
sponges,  is  diminished  by  proximity  to  the  fixed  rib-cartilages. 
If,  as  occasionally  happens,  the  foreign  body  can  be  felt,  the 
incision  through  the  parietes  is  best  made  directly  over  it.  And 
if  sign  of  perforation  show  at  any  part,  this  also  guides  to  the 
site  of  incision.  Labbe  recommended  an  incision  parallel  to  the 
left  costal  margins,  the  lower  end  of  which  did  not  descend 
below  the  level  of  the  tip  of  the  ninth  cartilage.  Bell  and  Neal 
made  use  of  an  incision  extending  from  the  umbilicus  towards 
the  left  false  ribs ;  Vidal  de  Cassis  made  his  incision  in  the 
middle  line  ;  and  other  incisions,  too  numerous  to  mention,  have 
been  employed. 

If  the  foreign  body  is  very  large,  as  in  Thornton's  case,  the 
incision  is  best  made  in  the  middle  line.  The  linea  semilunaris 
is,  for  most  cases,  too  far  outwards.  Labbe's  incision  is  probably 
as  good  as  any  for  those  cases  where  the  site  of  election  is  not 
determined  by  the  foreign  bod}'  being  felt.  The  incision,  begin- 
ning at  the  level  of  the  tip  of  the  ninth  rib-cartilage,  and  about 
an  inch  and  a  half  to  the  inner  side,  is  carried  upwards  parallel 
to  the  costal  margin  for  a  distance  of  two  and  a  half  or  three 
inches.  The  muscles  are  divided  and  the  peritoneum  opened  in 
the  same  way  as  in  gastrostomy. 

Now  that  the  competency  of  sutures  in  wounds  of  the  hollow 
viscera  to  prevent  escape  of  their  contents  has  been  abundantly 
proved,  the  old  practice  of  fixing  the  stomach  to  the  parietes 
need  not  be  followed.  The  stomach  may  be  opened,  sutured, 
and  returned  to  the  abdominal  cavity,  with  an  assurance  that, 
if  the  stitches  have  been  properly  placed,  there  will  be  no  escape 
of  gastric  fluids. 

When  the  peritoneal  cavity  is  entered,  two  fingers  are 
passed  over  the  anterior  surface  of  the  stomach,  to  feel  for 
the  foreign  body.  Occasionally  some  difficulty  in  detecting  the 
body  is  encountered.  If,  as  is  usually  the  case,  the  body  is 
long,  the  end  which  lies  most  conveniently  to  the  parietal  wound 
is  selected  as  the  site  of  the  stomachic  incision.     If  the  body  is 


THE   OPERATION.  373 

sharp-pointed  at  one  end  (as  a  fork),  the  blunt  end  is  chosen. 
Particular  care  must  be  taken  that  the  gastric  wall  is  not 
perforated  by  rough  handling  of  a  sharp-pointed  foreign  body. 
If  the  blunt  end  lies  at  considerable  distance  from  the  parietal 
incision,  it  will  be  wise  policy  to  open  the  stomach  over  the 
sharp  extremity-  In  the  case  of  collections  of  hair,  the  stomach 
may  be  opened  where  it  protrudes  most.  Each  case  must  be 
judged  on  its  merits  as  to  site  of  opening. 

When  the  spot  for  making  the  opening  has  been  selected, 
the  whole  surface  of  the  stomach  around  this  spot  is  covered 
with  flat  sponges.  Two  silver  or  silk  guiding  loops  are  inserted 
through  the  muscular  and  serous  coats  at  the  sides  of  the  pro- 
posed line  of  incision  ;  the  stomach  is  gently  pulled  to  the 
surface  by  these  loops,  the  ends  of  which  are  now  entrusted  to 
an  assistant,  who  keeps  the  stomach  pressed  up  against  the 
sponges  b}'  means  of  them.  The  line  of  incision  is  best  made 
parallel  to  the  course  of  the  vessels — that  is,  transversely  to  the 
curvatures,  or  in  a  line  with  the  abdominal  wound.  An  opening 
of  sufficient  size  is  made  between  the  loops  by  knife  or  scissors, 
and  the  forefinger,  inserted  through  it,  feels  the  body  and  enables 
the  surgeon  to  decide  upon  the  best  mode  of  extraction.  The 
finger  may  be  able  to  push  the  end  of  the  body  through  the 
wound,  when  it  may  be  caught ;  or  it  may  be  lifted  out  between 
the  forefinger  and  a  lithotomy  scoop  or  similar  instrument ;  or 
the  end  may  be  seized  in  suitable  forceps,  whereby  it  is  dragged 
out  of  the  wound.  Sometimes  the  body  is  found  embedded 
in  granulations,  which  bleed  freely  on  being  disturbed ;  the 
greatest  care  must  then  be  taken  to  avoid  perforation  of  the 
stomach.  During  the  manipulations,  the  assistant  takes  care 
that  the  sponges  are  well  placed  to  absorb  any  escaping 
fluid. 

When  the  foreign  body  has  been  removed,  it  may  be  wise, 
if  there  is  much  mucoid  or  purulent  or  bloody  material  in  the 
stomach,  to  cleanse  it  by  means  of  small  sponges  on  sponge- 
holders.  The  less  the  stomach  is  irritated  the  better,  however. 
Before  beginning  to  place  the  sutures,  a  very  soft  suitably  shaped 
flat  sponge  is  inserted  through  the  wound,  with  a  long  piece  of 


374 


GASTROTOMY. 


thick  silk  passed  through  it  to  draw  it  out  by  when  the  deep 
sutures  have  been  inserted  and  before  they  are  tied. 

The  best  form  of  suture  for  the  stomach  wound  is  the 
Lembert  (Fig.  51),  or  some  simple  modification  of  it.  The  best 
needle  is  a  milliner's  needle  of  medium  size  ;  the  suture  material 
should  be  fine  Chinese  twist.  The  sutures  are  most  easily  and 
rapidly  inserted  along  folds  of  the  stomach-wall  raised  by  trac- 
tion on  quilt  stitches   placed   about  two  inches  apart,  in  the 

manner  described    and   depicted 
^-^^  further     on     for     Enterorraphy. 

^y^  The  needle   passes   through  the 

serous,  sub-serous,  and  muscular 
coats,   piercing   but    not    cutting 

-  the   tissues,  and  does  not  enter 
_^         the  mucous  coat.      The  accom- 
panying diagram   (Fig.  51)  may 

■^  be  taken  as  representing  on 
natural  scale  the  mode  of  plac- 

—  ing  and  the  closeness  of  the 
sutures.  When  the  sutures  have 
been  placed,  their  ends  are 
gathered  together  in  the  blades 
of  catch  -  forceps,  the  threads 
crossing  the  middle  of  the 
wound  are  teased  apart,  and 
the  sponge  is  removed.  The 
sutures  are  then  systematically 
and  carefully  tied,  beginning  at 

one  end  and  going  on  to  the  other.  A  second  row  of  sutures, 
passing  through  peritoneum  alone,  is  sometimes  placed  in  alter- 
nation with  the  first  row.  These  sutures  are  ordinarily  inter- 
rupted, but  very  perfect  apposition  may  be  got  by  making  them 
continuous.  A  double  continuous  row,  where  the  sutures  cross 
and  the  free  ends  are  tied  together  at  the  end  of  the  wound,  may 
be  used  if  the  wound  is  small.  Appolito's  suture  (see  Enter- 
ectomy)  would  seem  to  be  very  suitable.  Expansion  and  con- 
traction takes  place  through  a  wider  range  in  the  stomach  than 


Fig.  51. 

Leviben's  Suture. 


THE   OPERATION.  375 

in  the  intestine.  The  continuous  suture  prevents  stretching  of 
the  intervals,  and  subsequent  escape  of  fluid  when  the  stomach 
expands  ;  if  the  stomach  contracts,  the  continuous  suture  might 
get  loosened.  Unless  the  stomach  is  quite  contracted,  which  is 
different  from  being  empty,  the  interrupted  suture  is  the  safer. 

When  the  stomach  wound  is  perfectly  closed,  the  sponges  are 
removed  from  the  abdominal  cavity.  A  dry  sponge  is  finally  inser- 
ted on  a  sponge-holder,  to  make  sure  that  no  foreign  matter  is  left 
behind.    The  parietal  wound  is  then  closed  in  the  ordinary  way. 

The  subsequent  treatment  consists  in  giving  absolute  rest  to 
the  stomach  for  three  or  four  days,  the  patient  being  fed  on  enemas 
meanwhile.  Very  small  quantities  of  peptonised  milk,  diluted 
with  water,  are  given  at  stated  intervals  for  two  or  three  days 
more  ;  and  then  beef  peptonoids  and  thin  broths  may  be  added 
to  the  diet,  while  the  intervals  of  feeding  may  be  lengthened  and 
the  amounts  of  food  increased.  At  the  end  of  a  fortnight,  starchy 
foods  may  be  given ;  and  at  the  end  of  three  weeks,  ordinary 
light  diet. 

If  vomiting  takes  place  at  any  time,  all  food  must  be  with- 
held till  it  has  ceased.  Separation  of  the  lips  of  the  wound  is 
more  likely  to  take  place  when  the  stomach  contracts  or  is  com- 
pressed over  fluid  contents,  than  when  it  is  empty. 

The  chances  of  successful  issue  are  very  good.  Mr.Thornton's 
case  made  an  admirable  recovery,  in  spite  of  his  having  to 
remove,  on  the  day  after  the  operation,  a  sponge  which  was 
inadvertently  left  inside  the  abdomen,  and  in  spite  also  of  sup- 
purative inflammation  of  the  parotid.  In  his  case  also  the 
stomach  wound  was  very  large.  When  closed,  it  measured 
three  inches.  There  is  no  other  record  of  a  foreign  body  of 
such  dimensions  having  been  removed  from  the  stomach. 

GASTROTOMY    FOR    REMOVAL    OF    FOREIGN    BODIES    IN    THE 
CESOPHAGUS. 

For  foreign  bodies  impacted  near  the  cardiac  extremity  of 
the  oesophagus,  when  all  attempts  to  remove  them  by  the  mouth 
have  failed,  gastrotomy  may  be  performed  with  the  view  of 
removing  them  through  the  stomach. 


376  GASTROTOAIY. 

Maurice  H.  Richardson  of  Harvard  University,  in  1886, 
introduced  the  operation  by  a  very  successful  case.  He  suc- 
ceeded, after  introducing  the  whole  hand  through  an  opening  in 
the  stomach,  in  removing  a  denture  of  teeth  impacted  in  the 
lower  portion  of  the  gullet.  Since  then  he  has  made  careful 
anatomical  observations  on  the  details  of  the  operation,  and 
studied  its  indications  and  possibilities.*  In  a  series  of  cases 
he  found  that  the  average  distance  from  the  incisors  to  the 
diaphragm  was  14^  inches  :  a  foreign  body  arresting  the  point  of 
the  probang  at  a  distance  of  13  inches  from  the  incisors  would 
therefore  be  near  to  the  cardia,  and  might  be  removed  by  gas- 
trotomy.  He  found  that  all  parts  of  the  oesophagus  were 
accessible  to  the  finger,  either  by  gastrotomy  or  external  oesopha- 
gotomy.  It  is  possible  with  the  fingers  of  the  left  hand  to  reach 
three  inches  above  the  cardiac  orifice. 

Richardson  recommends  an  oblique  incision  along  the  mar- 
gins of  the  left  ribs  long  enough  to  admit  of  the  introduction  of 
the  whole  hand.  The  vertical  incision  he  considers  best  for  the 
introduction  of  instruments.  The  stomach  is  pulled  to  the  sur- 
face and  carefully  isolated  with  sponges.  The  lesser  curvature 
is  put  on  the  stretch,  so  as  to  make  a  sulcus  between  the  ante- 
rior and  posterior  surfaces,  leading  straight  to  the  cardiac 
opening  and  serving  as  a  guide  for  the  introduction  of  instru- 
ments. The  site  of  the  incision  in  the  stomach  is  unimportant. 
It  must  be  far  enough  to  the  right  to  allow  of  the  passage  of  the 
instrument  along  the  sulcus,  as  described.  If  the  instrument  is 
brought  obliquely  to  this  groove  and  passed  upwards,  all  the  time 
being  pressed  gently  against  the  straightened  lesser  curvature,  it 
will  glide  into  the  oesophagus  every  time  with  the  greatest  ease. 

The  assistant,  standing  on  the  patient's  left,  holds  tlie 
stomach  by  the  greater  curvature  in  both  hands,  so  that  the 
whole  viscus  is  flattened  out.  "The  operator,  standing  on  the 
right  of  the  patient,  holds  the  lesser  curvature  between  the  left 
thumb  and  forefinger,  thereby  making  tense  the  lesser  curvature, 
and  assisting  in  the  passage  of  the  instrument.  Before  doing 
this  it  is  best  to  introduce  the  hand  into  the  peritoneal  cavity, 
*  Lancet,  Oct.  8th,   1887. 


THE   OPERATION.  377 

and  examine  the  diaphragmatic  opening  externally.  With  the 
stomach  held  as  described,  the  opening  through  its  walls  may  be 
made  anywhere  on  the  flattened  surface,  so  as  to  avoid  the  large 
vessels."  In  most  cases  the  foreign  body  may  be  removed  with 
a  suitable  instrument :  if  this  fails,  the  stomachic  incision  must 
be  enlarged,  and  the  whole  hand  introduced.  The  opening  in  the 
stomach  is  closed  by  the  Lembert  suture  in  the  ordinary  way. 

W.  T.  Bull  of  New  York,'''  in  recording  an  operation  of  this 
sort  successfully  performed  by  him,  makes  some  novel  and 
valuable  observations.  The  patient  was  a  boy  of  i6,  and  had 
swallowed  a  peach-stone,  which  was  found  firmly  impacted  in 
the  oesophagus,  at  a  distance  of  13  inches  from  the  incisors. 
After  ineffectual  attempts  to  dislodge  it  by  the  mouth.  Bull, 
through  a  median  vertical  incision  in  the  parietes,  made  a  small 
opening  in  the  stomach  just  large  enough  to  admit  the  finger. 
After  passing  sponges  into  the  abdominal  cavity  to  collect  any 
fluid  that  might  escape,  he  placed  four  loops  of  thread  in  the 
wall  of  the  stomach  around  the  opening,  and  then,  invaginating 
the  anterior  wall  of  the  stomach  while  the  finger  plugged  the 
opening,  pushed  the  finger  onwards  to  the  end  of  the  oesophagus. 
The  peach-stone  was  felt,  but  could  not  be  dislodged  by  finger 
or  forceps.  He  then  passed  a  fine  bougie  from  below  upwards 
past  the  stone  into  the  mouth  ;  attached  a  piece  of  sponge  by  a 
strong  -silk  ligature  to  the  end  of  the  bougie,  and  pulled  it 
through  the  mouth.  The  sponge  passed  by  the  foreign  body  ; 
but  a  second  and  larger  sponge,  attached  to  the  same  string, 
pulled  it  into  the  mouth. 

The  patient  made  an  excellent  recovery.  In  this  case  very 
thin  and  lax  parietes  made  the  operation  possible  without  passing 
the  hand  into  the  abdomen.  In  most  cases  it  would  probably 
be  necessary  to  pass  the  hand  inside  the  abdomen ;  but  it  need 
not  always  be  necessary  to  make  the  large  opening  into  the 
stomach. 

It  is  too  early  to  draw  conclusions  from  these  operations.  There 
can  be  no  doubt,  however,  that  they  present  a  valuable  means  of 
treating  a  peculiarly  difficult,  if  uncommon,  class  of  cases. 
*  New  York  Med.  Jourti.,  Oct.  29th,  1887. 


378  GASTROTOMY  FOR   TUMOURS. 


GASTROTOMY    FOR    REMOVING    CANCEROUS    GROV/THS    IN    THE 
STOMACH. 

Augustus  C.  Bernaj^s  of  St.  Louis  has  recently*  introduced 
to  the  profession  a  remarkable  operation,  whereby,  after  making 
an  incision  in  the  walls  of  the  stomach,  he  removes,  by  curette 
or  other  suitable  instrument,  cancerous  growths  bulging  into  the 
stomachic  cavity.  He  records  two  cases,  and  the  results  in 
each  were  so  strikingly  favourable  as  to  warrant  the  conclusion 
that  the  operation  he  has  introduced  is  worthy  of  a  full  trial  in 
the  hands  of  others. 

As  a  result  of  extended  study,  he  found  that  "  one-half  of  all 
cancers  of  the  stomach  start  near  the  pylorus,  and  that  in  nine- 
tenths  of  all  cases  they  have  a  tendency  to  grow  towards  the 
lumen  of  the  stomach.  In  the  beginning  the  mucous  membrane 
is  the  seat  of  the  disease ;  the  sub-mucous,  loose  connective 
tissue  is  next  attacked ;  and  only  in  the  last  stages  are  the 
muscular  and  serous  coats  invaded  by  the  neoplasm."  The 
muscular  layer  becomes  soon  hypertrophied,  but  it  is  last 
invaded ;  "  cancer  of  the  stomach  originally  grows  inside  the 
muscular  layer,  towards  the  lumen  of  the  organ." 

Reasoning  from  these  facts,  and  from  the  analogy  of  results 
got  after  curetting  similar  cancers  elsewhere,  Bernays  decided, 
as  an  alternative  to  other  impossible  or  unsatisfactor}^  operations, 
to  give  certain  selected  cases  a  trial  by  scraping  or  curetting. 
He  first  made  an  accurate  examination  of  the  parts  from  the 
outside  of  the  stomach ;  then  fixed  a  fold  of  the  stomach  to 
the  parietal  wound  by  numerous  sutures.  He  then  opened  the 
stomach  and  carefully  stitched  the  lips  of  the  opening  to  the 
lips  of  the  wound  in  the  parietes.  The  stomachic  cavity  being 
thus  completely  shut  off  from  the  abdominal  cavity,  he  proceeded 
with  fingers  and  curettes  to  tear  and  scrape  away  masses  of  the 
growth.     The  bleeding  was  free,  but  soon  ceased. 

The  stomach  remaining  attached  to  the  parietes,  the  opera- 
tion may  be  repeated  without  performing  laparotomy  when  the 
*  Annals  of  Surgery,  Dec,  1887. 


GASTROTOMY  FOR   TUMOURS.  379 

renewed  growth  of  the  tumour  calls  for  it.     The  gastric  fistula 
may  or  may  not  be  closed. 

For  a  full  account  of  the  operation,  and  a  history  of  the 
cases,  I  must  refer  the  reader  to  Bernays'  paper.  As  an  alter- 
native to  such  operations  as  gastro-enterotomy  and  pylorectomy, 
where  these  are  impossible,  the  operation  seems  to  me  to  have 
already  assumed  a  justifiable  position ;  and,  even  in  cases  where 
these  are  possible,  it  seems  likely  that  Bernays'  operation  will 
appear  as  a  worthy  competitor. 


Gastrorraphy. 

Gastrorraphy  (r^^aaTrjp — stomach,  and  /5(/0/} — suture)  is  here 
used  to  mean  the  closure  of  a  wound  or  opening  in  the  stomach. 
In  its  old  sense,  as  meaning  suture  of  a  wound  in  the  abdominal 
parietes,  the  word  may  now  be  considered  obsolete. 

History. — According  to  Wolfler,'-'  a  Bavarian  surgeon  in  1521 
first  performed  Gastrorraphy.  So  far  as  I  know,  Billroth!  is 
the  only  living  surgeon  who  has  performed  the  operation.  His 
case  was  one  of  gastric  fistula,  which  he  had  failed  to  cure  by 
plastic  operation.  Gastric  fistula  is  not  common :  Murchison 
was  able  to  find  records  of  only  twenty-five  cases  in  a  period 
extending  over  three  centuries  ;  therefore,  operations  for  the 
cure  of  it  must  always  be  rare. 

Conditions  indicating  Operation.  —  Cases  of  gastric  fistula,  in 
which  the  stomachic  contents  are  constantly  dribbling  away,  or 
in  which  the  food  taken  by  the  mouth  freely  escapes,  and  which 
have  resisted  all  other  treatment  to  alleviate  or  cure,  are  legiti- 
mate subjects  for  gastrorraphy.  Fistulae  arising  from  ulcerative 
destruction  by  malignant  diseases  are,  of  course,  unsuitable  for 
operation.  Perforating  ulcer  of  the  stomach,  the  most  common 
non-traumatic  cause  of  gastric  fistula,  may  pass  through  the 
parietes  by  direct  extension,  or  through  an  intervening  abscess ; 
in  the  latter  case  we  may  expect  more  inflammatory  thickening 
than  in  the  former,  and  the  operation  will  be  correspondingly 
difficult.  The  site  of  the  fistula  is,  however,  the  most  important 
consideration.  If,  as  in  St.  Martin's  case,  it  lies  between  the 
ribs,  the  operation  would  be  complicated.  If,  as  in  Maillot's 
case,  it  lies  close  to  the  ensiform  cartilage,  the  operation  would 
be  difficult.  But,  if  it  is  well  free  of  the  bony  parts,  it  need 
present  no  great  obstacles  to  successful  performance. 

Cases  of  perforating  ulcer  of  the  stomach  can,  when  perfora- 
tion has  taken  place,  be  saved  from  certain  death  only  by  the 

*   Ueber  die  .  .  .  Resedionen  des  Carcinomatosen  Pylorus.     Wien,  1881. 
t   Wiener  vied.  Wochenschrift,  1887,  No.  38. 


THE   OPERATION.  381 

performance  of  gastrorraphy.  Two  or  three  such  operations 
have  been  performed  ;  one,  at  least,  with  success.  When,  with 
a  clear  history  of  ulcer  of  the  stomach,  undeniable  symptoms  of 
perforation  suddenly  come  on,  abdominal  section,  cleansing  of 
the  cavity,  and  closing  of  the  stomach-opening,  give  the  patient 
the  only  chance  of  life.  A  very  slight  chance  of  success  would 
justify  the  operation. 

Traumatic  wounds  of  the  stomach,  by  bullets,  knives,  or 
other  means,  justify  gastrorraphy  or  not,  according  to  principles 
which  will  be  discussed  when  the  whole  question  of  perforative 
wounds  of  the  hollow  viscera  is  considered. 


THE    OPERATION. 

For  gastric  fistula,  the  operation  is  preceded  by  a  thorough 
washing  out  of  the  stomach  by  an  alkaline  solution.  If  the 
fistula  be  large  enough,  several  soft  sponges,  with  long  pieces 
of  string  attached,  are  passed  into  the  stomach  and  pulled  out- 
wards against  the  opening  by  an  assistant.  These  prevent  the 
escape  of  mucus,  steady  the  organ,  and  absorb  any  blood  that 
may  be  lost  during  subsequent  proceedings.  They  need  not  be 
rem.oved  till  the  first  row  of  sutures  is  placed  in  the  stomach- 
wall. 

The  parietal  incision,  about  three  inches  in  length,  passes 
through  the  fistulous  opening,  and  is  made  in  an}'  direction  that 
seems  most  convenient.  The  peritoneum  is  divided  at  one 
extremity  of  the  wound,  so  as  to  get  beyond  the  adhesions  which 
fix  the  stomach  to  the  parietes.  The  finger  inserted  through 
this  opening  carefully  separates  the  adhesions  up  to  the  fistulous 
opening,  and  as  soon  as  possible  sponges  are  packed  into  the 
abdominal  cavity.  The  adhesions  at  the  other  extremity  of  the 
wound  are  separated  in  the  same  way  with  finger  and  finger- 
nail. When  the  stomach  has  been  freed,  the  fistulous  opening 
is  drawn  to  the  surface  by  means  of  the  strings  attached  to  the 
sponges  inside  the  stomach.  In  most  cases  it  will  be  wise  to 
freshen  the  edges  of  the  fistula  in  the  stomach  by  means  of 
scissors ;  and  in  doing  so,  as  little  of  the  tissue  as  possible  will 


382  GASTRORRAPHY. 

be  removed.  The  stitches  are  placed  as  in  gastrotomy,  the 
sponges  being  removed  before  they  are  tied.  The  fistulous  tract 
in  the  abdominal  wall  is  cut  away.  The  subsequent  steps  are 
exactly  as  in  gastrotomy,  and  the  after-treatment  is  the  same. 

In  perforating  ulcer  of  the  stomach,  we  have  little  experience  to 
guide  us.  The  oblique  incision  recommended  for  gastrostomy 
would  probably  satisfy  all  requirements.  It  might  with  advan- 
tage be  half  an  inch  further  away  from  the  ribs,  and  it  might 
extend  a  little  higher.  If  the  perforation  is  in  front,  the 
stomachic  contents  will  have  escaped  into  the  greater  cavity  of 
the  peritoneum,  and  will  be  at  once  visible.  If  the  perforation 
is  behind,  the  contents  may  be  confined  to  the  lesser  cavity  of 
the  peritoneum,  and  it  may  be  necessary  to  tear  through  the 
anterior  layers  of  the  great  omentum  to  get  at  the  opening  in 
the  stomach. 

When  the  extravasated  fluids  are  seen,  wherever  they  be, 
the  first  thing  to  be  done  is  rapidly  to  pass  sponges  into  the 
cavity,  so  as  to  soak  them  up.  If  the  opening  in  the  stomach 
can  be  seen,  the  subsequent  proceedings  are  now  simple  enough  : 
to  pare  the  edges  of  the  ulcer,  and  suture  the  opening.  If  it  is 
not  seen,  the  stomach  surface  is  carefully  and  systematically 
explored  with  the  fingers,  and  by  pulling  it  towards  the  abdo- 
minal opening  for  inspection.  If,  after  most  careful  examination, 
no  perforation  is  found  on  the  anterior  surface,  the  posterior 
surface  must  be  explored.  To  do  this,  the  anterior  layers 
of  the  great  omentum  must  be  perforated.  A  convenient  spot 
is  selected  midway  between  the  transverse  colon  and  the  greater 
curvature  of  the  stomach,  and  an  opening  large  enough  to 
admit  the  finger  is  teased  out  with  forceps.  This  opening  is 
enlarged  by  slow  dilatation  with  the  fingers  ;  no  vessels  need  be 
severed.  Perforation  of  the  posterior  surface  of  the  stomach 
will  be  shown  by  the  escape  of  gastric  contents  through  this 
opening,  and  then  the  finding  of  the  site  of  perforation  is  merely 
a  question  of  time  and  tactile  sensibility.  To  bring  it  into  view 
may  not  be  easy.  If  the  ulcer  lies  near  the  greater  curvature, 
it  can  be  rendered  visible  and  brought  within  the  reach  of  the 
fingers  for  manipulation.    If  the  perforation  lies  high  up  behind, 


OPERATION   FOR   PERFORATION.  383 

it  may  be  very  difficult  to  bring  it  into  view,  and  still  more 
difficult  to  place  sutures  around  it.  By  a  properly  arranged  and 
sufficiently  long  incision,  I  have  found,  post-mortem,  that  it  is 
always  possible  to  render  every  part  of  the  posterior  surface  of 
the  stomach  visible  through  an  opening  made  in  the  great 
omentum,  and  that,  with  the  help  of  sponges  and  retractors, 
sutures  may  be  placed  an3-where  in  the  stomach  walls. 

If  it  is  found  very  difficult  to  suture  the  perforation  in  the 
posterior  surface,  I  would,  rather  than  leave  the  operation 
unfinished,  recommend  incision  of  the  stomach  in  front,  pushing 
the  perforated  part  through  the  incision  by  the  forefinger  placed 
behind,  and  suturing  of  the  ulcerated  opening  from  the  mucous 
surface.  To  pinch  up  a  fold  of  stomach  on  its  mucous  aspect 
and  insert  a  few  sutures,  would  give  accurate  peritoneal  apposi- 
tion. The  incision  in  the  stomach  would  then  be  closed  as  in 
gastrotomy  for  foreign  bodies. 

After  any  operation  for  perforating  ulcer  of  the  stomach,  the 
abdominal  cavity  should  be  well  washed  out  by  a  stream  of  warm 
aseptic  fluid. 


Operative  Dilatation  of  the  Orifices  of  the 
Stomach. 

History. — Professor  Loreta  of  Bologna  introduced  this 
operation ;  though  Richter  of  Breslau  first  suggested  it.*  In 
September,  1882,  Loreta  performed  his  first  operation,!  a  notice 
of  which  was  first  suppHed  to  British  readers  by  Mr.  Holmes. | 
Up  to  the  present  he  has  operated  about  thirty  times.  A  few 
other  surgeons,  chiefly  Italian,  have  performed  the  operation. 
McBurney  of  New  York  has  operated  twice.  Barton  of  Phila- 
delphia §  has  operated  twice.  Treves  of  London  has  operated 
once.  In  a  case  with  advanced  cancer  of  the  stomach  for  which 
gastro-enterostomy  was  contemplated,  I  found  great  contraction 
of  the  pylorus,  which  I  dilated  through  an  opening  made  in  the 
stomach,  the  patient  recovering  well  and  being  benefited. 
Barton  II  has  collected  twenty-five  published  operations,  and  has 
heard  of  about  eighteen  more.  The  general  mortality  would 
seem  to  be  about  40  per  cent.  :  performed  sufficiently  early  and 
with  proper  skill,  the  operation  should  not  have  a  mortality  of 
over  10  per  cent.  The  cases  are  too  few,  and  the  operations  are 
too  recent,  for  formulating  any  conclusion  as  to  the  permanent 
value  of  the  proceeding.  So  far,  the  results  have  been  most 
gratifying. 

The  Aim  of  the  Operation. — The  operation  is  intended  only  for 
cases  of  non-malignant  character, — simple  cicatricial  or  fibrous 
narrowing  of  the  pylorus  or  the  cardia,  or  the  lower  end  of  the 
oesophagus.  With  such  narrowing  there  is  usually  found  con- 
siderable hypertrophy  of  the  inorganic  muscular  fibre,  and  the 
stretching  of  this  circle  of  muscle  is  an  important  element  in  the 
operation.  Professor  Loreta  justly  compares  his  operation 
with  that  of  over-distension  of  fibrous  stricture  of  the  rectum, 

*  Deutsche  vied.  Woch.,  1882,  p.  381. 

t  Afemoire  dell'  Accademia  delle  Scienze  Instituo  di  Bologna,  ser.  iv.,  vol  iv. 

\  Brit.  Med.  Joiirn.,  Feb.  21st,  1885. 

§  Med.  and  Surg.  Rep.,  VhWa..,  K^rW  13,  1889,  and  N.  Y.  Med.  Rec. , 'M.diy  2sih,  1889. 

II  N.  Y.  Med.  Rec.,  May  25th,  1889. 


DIAGNOSIS.  385 

which  is  well  known  to  be  highly  successful.  As  dealing  with 
simple  narrowing  of  the  pylorus,  the  operation  is  intended 
to  replace  pylorectomy  ;  for  narrowing  of  the  lower  oesophagus 
and  cardia,  it  takes  the  place  of  gastrostomy  for  simple 
stricture. 

The  diagnosis  is  important.  In  pyloric  obstruction  the  patient 
is  greatly  emaciated,  but  the  symptoms  will  have  lasted  so  long 
as  to  exclude  cancer.  The  stomach  is  much  dilated,  and  the 
diagnosis  is  then  between  dilatation  "  due  to  pyloric  obstruction 
and  that  due  to  idiopathic  gastritis."  In  forming  the  diagnosis, 
Prof.  Loreta  places  most  value  on  the  chemical  and  microscopical 
examination  of  the  contents  of  the  stomach.  When  positive 
results  are  got  from  the  examination  of  matters  rejected  or 
extracted^  we  may  conclude  that  the  dilatation  of  the  stomach  is 
idiopathic  ;  when  the  results  are  negative,  we  may  infer  dilatation 
from  mechanical  obstruction.  In  mechanical  dilatation  the 
gastric  contents  give  an  acid  reaction,  and  no  traces  of  albumen 
or  peptones  are  found.  In  the  other  forms  of  dilatation  the  re- 
action is  usually  neutral  or  alkaline,  rarely  acid,  and  the 
albuminoid  substances  are  found  unchanged  or  nearly  so. 
Other  and  more  elaborate  instructions  for  making  a  diagnosis 
are  given  by  Prof.  Loreta. '•=  Speaking  generally,  a  greatly 
dilated  stomach,  vomiting  without  nausea  and  with  slight 
effort  of  great  quantities  of  fluid,  obstinate  constipation  over 
which  purgatives  have  no  effect,  and  a  history  of  gastric  ulcer, 
may  be  taken  as  indicating  pyloric  obstruction. 

The  diagnosis,  in  simple  stricture  of  the  lower  end  of  the 
oesophagus  and  beginning  of  the  cardia,  is  more  easy.  In  most 
cases  there  will  be  a  history  of  the  swallowing  of  caustic  fluid ; 
in  all  there  will  be  an  absence  of  the  signs  of  cancer ;  and  the 
ordinary  signs,  subjective  and  objective,  of  oesophageal  obstruc- 
tion will  be  present.  In  this  case  it  is  presumed  that  attempts 
to  dilate  the  stricture  by  the  mouth  have  failed,  and  that  the 
so-called  "  tubation  of  the  gullet  "  is  either  impracticable  or 
devoid  of  result. 

*  See  Brit.  Med.  Joiirn.    1885,  i.,  p.  373. 
26 


386  LORETA'S   OPERATION. 

THE    OPERATION. 

For  operating  on  the  pylorus,  Loreta  at  first  made  his 
parietal  incision,  about  five  inches  in  length,  "  on  the  right  of  the 
median  line,  the  upper  and  inner  end  being  about  four  centi- 
metres below  the  xiphoid  cartilage,  the  lower  and  outer  end 
three  centimetres  from  the  cartilage  of  the  ninth  rib."  He  now 
makes  the  incision  in  the  linea  alba.  The  muscles  and  peritoneum 
are  divided  in  the  ordinary  manner.  The  pylorus  is  felt  for,  and 
will  be  found  thickened  and  hardened,  and  perhaps  adherent  to 
surrounding  organs.  The  coats  of  the  stomach,  lifted  out  of  the 
wound  as  far  as  necessary,  are  then  pinched  up  into  a  fold,  and 
divided  by  scissors  midway  between  the  two  curvatures  about 
an  inch  from  the  pylorus,  or  more  if  necessary.  Any  bleeding  is 
stopped  by  forci-pressure.  (Loreta  says  nothing  of  placing 
sponges  around  the  site  of  incision  in  the  stomach,  to  protect 
the  bowels  and  collect  extravasated  blood  or  gastric  fluids.) 
The  right  forefinger,  introduced  through  the  opening  in  the 
stomach,  is  pushed  into  the  pyloric  opening,  while  the  left  fore- 
finger steadies  it.  Considerable  force  and  great  patience  may 
be  required  to  overcome  the  powerful  grip  of  the  narrowed 
orifice.  When  the  finger  is  passed  through  the  opening,  the 
pylorus  may  be  hooked  downwards  towards  the  abdominal 
wound,  and  then  the  left  forefinger  is  also  insinuated  through  the 
stricture.  Even  with  the  fingers  thus  opposed,  the  resistance 
offered  to  dilatation  ma}^  appear  almost  insuperable.  After  a 
time  the  muscle  yields,  and  the  dilatation  is  continued  till  a 
sensation  is  felt  as  if  further  distension  would  result  in  tearing. 
The  fingers  are  kept  in  the  opening  thus  dilated  for  a  few 
minutes.  In  Loreta's  first  case  the  fingers  were  more  than  three 
inches  apart  as  they  lay  in  the  opening. 

The  wound  in  the  stomach  is  then  sewn  up,  the  stomach 
returned  to  its  place,  and  the  abdominal  incision  closed.  The 
after-treatment  is  that  of  gastrotom}'. 

In  operating  upon  stricture  of  the  cardia  and  lower  oeso- 
phagus, the  parietal  incision  Is  the  same,  only  on  the  opposite 
side.     The  difficulty  of  the  operation  is  likely  to  be  increased  by 


THE  OPERATION.  387 

the  contracted  condition  of  the  stomach.  When  the  viscus  is 
drawn  out  of  the  opening  as  far  as  is  safe,  a  longitudinal  incision 
is  made  between  the  two  curvatures  as  near  to  the  cardia  as 
possible.  There  may  be  some  difficulty  in  finding  the  orifice  of 
the  gullet  by  exploring  with  the  finger  inside  the  stomach ;  if  so, 
the  left  forefinger  carried  between  the  lesser  curvature  and  the 
under  surface  of  the  liver,  will  be  of  assistance  by  localising 
the  situation  of  the  gullet.  The  next  step  is  to  introduce  the 
dilator,  guided  by  the  forefinger  in  the  stomach.  The  dilator 
which  Loreta  used  is  made  "something  like  that  which 
Dupuj^tren  introduced  for  lithotomy,  only  longer,  measuring 
about  eight  inches  from  the  joint  to  the  end  of  the  blades,  and 
so  constructed  that  the  blades  would  not  separate  more  than  five 
centimetres."  When  the  instrument  is  introduced  the  blades 
are  dilated  to  the  full  extent ;  thus  dilated,  the  instrument  is  run 
up  and  down  the  oesophagus  several  times. 

The  subsequent  steps  of  closure  of  the  wounds  in  the  stomach 
and  parietes,  and  the  after-treatment,  require  no  description.  It 
is  curious  that,  in  two  cases  operated  upon,  there  appeared  on 
the  fourth  day  serious  disturbances  of  the  circulation  and  respi- 
ration, with  abundant  secretion  of  mucus  from  the  trachea  and 
bronchi ;  and  these  symptoms,  in  both  cases,  lasted  over  five 
days.  This  condition  Loreta  is  inclined  to  attribute  to  an 
exudative  hyperaemic  process. 

It  is  somewhat  surprising  that  so  few  surgeons  have  adopted 
Loreta's  operation.  Forcible  dilatation  of  the  oesophagus  b}^ 
the  mouth  has  not  been  attended  with  much  success,  and  this 
may  have  deterred  surgeons  from  imitating  Loreta's  proceeding 
through  an  incision  in  the  stomach.  But  this  objection  does 
not  hold  with  respect  to  pyloric  dilatation.  It  is  certain  that 
many  cases  diagnosed  during  life  as  pyloric  cancer  turn  out, 
post-mortem,  to  be  nothing  more  than  pyloric  obstruction, 
mainly  produced  by  enormous  hypertrophy  of  the  muscular 
tissue.  In  the  last  five  years  I  have  seen  at  least  three  such 
cases  ;  and  the  facts  were  specially  impressed  upon  me,  because 
I  had  spent  much  time  in  examining  with  the  microscope  for 

26  - 


388  LORETA'S   OPERATION. 

the  cancer  which  was  supposed  to  be  present,  and  found  nothing 
but  inorganic  muscle.  Such  cases  ought  to  be  diagnosed  ;  and 
if  diagnosed,  they  are  susceptible  of  great  improvement,  if  not 
of  permanent  cure,  by  Loreta's  operation.  Pylorectomy  has 
been  performed  for  at  least  one  case  of  cicatricial  contraction  : 
in  the  face  of  the  proved  success  of  forcible  dilation,  removal  of 
the  pylorus  would  seem  to  be  doing  too  much. 


Pylorectomy.     Partial  Gastrectomy. 

By  Pylorectomy  is  meant  removal  of  the  pylorus  and  so 
much  of  the  duodenum  and  stomach  as  may  be  involved  in  the 
disease  for  which  the  operation  is  performed.  The  operation 
may  thus  be  a  partial  Enterectomy  as  well  as  a  partial  Gas- 
trectomy. 

History. — According  to  Blum,*  Merrein,  in  1810,  first  con- 
ceived the  idea  of  removing  the  p3dorus.  A  little  later  Gunther 
practised  the  operation  on  dogs.  Gussenbauer  and  v.  Wini- 
water,  f  in  1876,  demonstrated  b}^  experiments  on  animals  that 
gastrectoni}^  was  a  feasible  operation.  Kaiser,  at  Czerny's 
instigation,  I  repeated  these  operations  with  success ;  and 
Wehr  ;   further  continued  the  experiments. 

Pean,||  in  1879,  first  performed  the  operation  on  a  human 
being,  but  without  success.  Rydygier,  in  1880,  performed  the 
second  operation,  also  unsuccessfully.  Billroth,  who  performed 
his  first  operation  on  Jan.  25th,  1881,  is  the  chief  exponent  of 
the  operation  ;  and,  through  the  writings  of  his  assistant  Wolfler, 
has  been  chiefly  instrumental  in  bringing  it  before  the  profession.^ 

Conditions  for  which  the  Operation  may  he  Performed. — Thus  far 
the  operation  has  been  performed  almost  entirely  for  cancer  of 
the  pylorus.  It  has  five  times  been  performed  for  ulcer  of 
the  stomach  in  the  pyloric  region,  and  once  successfully  for 
cicatricial  stenosis.  Billroth,  Czerny,  and  others  strongly 
advocate  it  for  non-malignant  forms  of  pyloric  obstruction, 
ulcerative  or  cicatricial,  whether  originating  pathologically  or 
after  traumatism,  as  from  swallowing  corrosive  liquids.  Fen- 
wick  relates  a  case  of  cicatricial  stenosis  after  injury,  which 
might  come  under  this  category. 

*  Arch.  Gen.  de  Med.,  vol.  cl.,   1882,  p.  332. 

t  Langenbeck's  Arcliiv.,  bd.  xix.,  p.  347. 

I  Beitragcn  ziir  Operativen Chirurgie.  Stuttgart,  1878.  §  Zeitschr.f.Cliir., 1882, p.  93. 

II  Gaz.  des  hop.,  No.  60,  1879. 

H    Uebey  die  von  Herrn  Professor  Billroth  Ausge/iirhten  Resectionen  des 

Carcinomatosen  Pylorus.      Vienna,  1881. 


390  PYLORECTOMY. 

For  non-malignant  forms  of  pyloric  obstruction  most  surgeons 
would  probably  prefer  Loreta's  operation  of  forcible  dilatation 
— at  least,  as  a  primary  proceeding.  And  for  ulcer,  unless  it 
lies  in  the  pylorus,  a  very  limited  gastrectomy  might  be  con- 
sidered more  advisable.  Still,  if  under  any  circumstances  the 
operation  is  justifiable,  it  will  continue  to  be  so  for  certain  cases 
of  non-malignant  stenosis  or  obstruction. 

Certain  cases  of  pyloric  obstruction  are  produced  by  strong 
peritoneal  adhesions  compressing  the  bowel  from  the  outside. 
These  are  peculiarly  suitable  for  operative  interference — not, 
however,  by  pyloric  resection,  but  by  dividing  the  adhesions. 
Obstruction  caused  by  pressure  from  a  tumour  outside  is  re- 
mediable or  not,  according  as  the  tumour  is  removable  or  not. 

Cancer  of  the  pylorus  remains  as  the  leading  indication  for 
pylorectomy.  The  majority  of  cases  of  cancer  of  the  stomach 
are  situated  at  or  near  the  pylorus:  according  to  Gussenbauer 
and  V.  Winiwater,  of  903  cases  of  gastric  cancer,  542  were 
pyloric.  In  a  surgical  sense  it  is  important  to  note  that  at 
death  in  223  of  these  cases  there  were  found  no  peritoneal 
deposits,  and  in  172  there  were  no  adhesions.  Rokitansky  has 
observed  that  cancer  of  the  pylorus  scarcely  ever  extends  into 
the  duodenum.*  There  is  always  considerable  hypertrophy  of 
the  muscular  tissue  surrounding  the  diseased  area,  and  the 
obstruction  may  be  due  as  much  to  the  inability  of  this  mass  to 
contract  as  to  the  ingrowth  of  the  tumour. 

In  making  the  physical  diagnosis,  it  is  recommended  that  the 
patient  be  anaesthetised.  Special  attention  is  paid  to  the  range 
of  mobility  of  the  tumour,  to  its  size,  and  to  the  nature  of  its 
surface — whether  it  is  smooth  or  nodulated.  If  the  tumour  is 
freely  movable,  we  may  infer,  with  a  high  degree  of  probability, 
that  there  is  no  invasion  of  neighbouring  organs.  In  one  case 
the  tumour  was  freely  movable,  yet  the  adhesions  were  so  strong 
and  so  numerous  that  the  operation  had  to  be  abandoned.  On 
the  other  hand,  fixation  does  not  so  certainly  indicate  extension 
of  the  disease.  Mobility  is  an  effect  of  dilatation  of  the  stomach ; 
if  extensive  dilatation  does  not  exist,  the  pylorus  may  not  have 
*  See  Billroth's  Clinical  Surgery,  New  Syd.  Soc,  p.  494. 


MORTALITY.  391 

been  disturbed  from  its  natural  situation.  A  greatly  dilated 
stomach,  with  fixation  of  the  pylorus  in  an  abnormal  situation, 
strongly  suggests  extension  of  the  disease  :  if  irregularity  of  the 
surface  of  the  growth  co-exists  with  these  conditions,  we  may 
certainly  infer  that  the  disease  has  spread,  and  then  operation 
is  out  of  the  question.  Free  mobility  has  been  found  associated 
with  invasion  of  lymphatic  glands;  this  can  be  discovered  only 
after  proceeding  to  operate. 

There  must  be  present  unequivocal  symptoms  of  pyloric 
obstruction.  Dilatation  of  the  stomach  will  usually  be  the 
most  important  symptom.  If  there  is  any  doubt  as  to  this 
condition,  it  will  be  advisable  to  verify  it  by  the  generation 
of  carbonic  acid  gas  in  the  stomach  by  drinking  two  solutions 
one  after  the  other,  which  when  mixed  will  evolve  the  gas.  The 
history  is  important.  From  other  species  of  pyloric  obstruction, 
cancer  differs  in  producing  local  pain  and  impairment  of  appetite. 
In  cases  not  cancerous,  pain  is  not  a  prominent  symptom,  and 
the  appetite  may  be  increased,  often  to  voracity.  INIore  than 
one  observer  has  noted  that,  in  cases  of  cancer  of  the  stomach, 
hydrochloric  acid  is  not  found  in  the  gastric  juice. 

Mortality  and  Appreciation. — The  operation  is  a  very  fatal  one. 
Mikulicz  of  Cracow*  collected  32  cases,  of  which  only  8  re- 
covered from  the  effects  of  the  operation.  Up  to  the  end  of 
1887  Billroth!  is  reported  to  have  operated  i8  times,  saving  8 
patients  for  a  longer  or  shorter  time.  One  had  lived  five  years. 
Winslow :[:  has  tabulated  records  of  61  cases,  which  he  believes 
to  be  all  the  operations  performed  up  to  date  of  writing.  Of  these, 
16  recovered  and  44  died  ;  in  one  case  the  result  was  unknown. 
Collapse  was  the  chief  cause  of  death,  claiming  27  of  all  the 
cases.  Peritonitis,  pure  and  simple,  is  not  a  frequent  termi- 
nation— a  fact  which  speaks  volumes  for  the  technical  skill  of 
the  operators.  Four  of  Winslow's  cases  died  of  gangrene  of 
the  colon,  and  a  fifth  case  has  since  been  recorded. §     In  a  large, 

*  Wiener  med.  Woch.,  Nos.  23  and  24.        t  Obstet.  Gaz.  Cincin.,  Oct.,  1887. 

X  Amer.  Journ.  of  Med.  Sc.,  April.,  1885. 

§  Lauenstein,  Ccntralbl.  fiir  Chiriirgie,  1882,  No.  9;    March  28th,   1S85;    and 
Feb.  2ist,  1885.     Also,  Rydygier,  Ibid.,  March  28th,  1885. 


392  PYLORECTOMY. 

and  as  yet  not  fully  reported,  number  of  cases  recurrence  takes 
place  a  few  months  after  operation.  No  case,  according  to 
Winslow,  has  lived  longer  than  three  years  without  signs  of 
recurrence.  Six  cases  of  non-carcinomatous  stricture  have  been 
recorded,  with  three  recoveries.  In  these,  of  course,  recurrence 
is  not  to  be  expected. 

The  most  recent  statistics  are  at  once  contradictory  and  un- 
promising. Mc  Ardle*'  has  collected  records  of  70  operations — 
8  for  simple  stricture,  62  for  cancer.  Of  the  former,  5  recovered 
and  3  died;  of  the  latter,  21  died  directly  from  the  operation, 
14  from  peritonitis  or  septic  absorption;  "the  remaining  27  made 
good  recoveries,  many  of  them  being  reported  well  four  years 
after  operation."  It  is  a  pity  that,  in  this  report,  fuller  details  of 
the  cases  were  not  given;  for  then  it  might  have  been  possible  to 
explain  the  remarkable  discrepancy  with  Butlin's  painstaking 
studies,!  which  seem  to  demonstrate  that,  thus  far,  not  one  case 
of  those  which  recovered  from  operation  can  be  claimed  to  have 
been  really  cured  of  the  disease. 

With  these  results  before  us,  we  must  admit  that  if  pylo- 
rectomy  is  to  be  considered  anything  more  than  a  mere 
"  surgical  exercise,"  it  is  to  be  contemplated  only  in  a  very 
carefully  selected  class  of  cases.  If  the  patient  is  not  in  fairly 
good  condition,  if  the  stomach  is  greatly  dilated,  if  the  growth 
is  large,  fixed  and  displaced,  the  operation  ought  not  to  be  con- 
templated. And,  even  when  the  obverse  conditions  are  present, 
it  is  doubtful  if  it  could  ever  be  a  surgeon's  duty  to  advise  the 
operation ;  he  ought  to  undertake  it  only  at  the  patient's  urgent 
request,  and  after  fully  and  honestly  explaining  to  him  the 
hazardous  risk  which  he  undergoes. 


THE    OPERATION. 

Before  operation,  the  stomach  must  be  thoroughly  cleansed 
by  irrigation  through  a  stomach-tube.  If  there  is  fermentation 
of  the  gastric  contents,  an  antiseptic  such  as  boro-glyceride 
should  be  used  in  the  solution.     A  final  cleansing    should   be 

*  Dithlin  Jotirn.  Med.  Sc,  June,  1887.      t  Operat.  Surg,  of  Malig.  Dis.,  page  221. 


PARIETAL   INCISION.  393 

carried  out  not  more  than  two  hours  before  operation ;  and  the 
whole  of  the  fluid  should  be  removed,  so  as  to  have  the  stomach 
empty  at  the  operation.  It  is  unwise  to  operate  if  the  stomach 
is  greatly  distended,  for  an  over-dilated  stomach  must  be  badly 
nourished  and  intolerant  of  operative  interference.  The  amount 
of  distension  may  be  readily  ascertained  by  percussion  after  a 
seidlitz  powder  has  been  administered  in  separate  draughts — 
one  draught  containing  the  acid  and  the  other  the  alkali. 

The  operation  may  be  described  in  successive  stages :  the 
incision  in  the  parietes  ;  the  isolation  of  the  pylorus ;  its  resec- 
tion ;  and  the  closing  of  the  wound  in  the  stomach,  and  the 
uniting  of  the  duodenum  to  it. 

The  Parietal  Incision. — Various  lines  of  incision  have  been 
recommended.  Pean  and  Rydygier  used  vertical  incisions — the 
former  in  the  middle  line,  the  latter  a  little  to  the  right  of  it. 
Others  have  employed  incisions  more  or  less  oblique,  or  almost 
transverse,  Billroth  and  Wolfler  made  their  incisions  almost 
transverse,  and  most  other  surgeons  have  followed  their  example. 
It  is  evident  that  the  greatest  space  for  manipulation  will  be 
secured  by  an  opening  made  in  the  line  of  the  long  axis  of  the 
stomach,  and  the  pylorus  ought  to  be  very  near  the  middle  of 
this  opening.  If  the  pylorus  has  sunk  low  down  in  the  abdomen, 
Wolfler  recommends  that  it  should  be  elevated  before  the  in- 
cision is  made.  This  would  undoubtedly  give  the  full  benefit  to 
the  operator  of  the  relaxation  of  parts  which  permits  of  the 
descent  of  the  organ. 

The  first  incision,  made  over  the  pylorus  in  the  line  of  the  long 
axis  of  the  stomach,  need  be  no  more  than  two  inches  in  length. 
Through  this  small  opening  the  pylorus  is  thoroughly  explored, 
and  a  decision  is  come  to  as  to  the  possibility  of  removing  it, 
and  the  best  course  in  which  to  prolong  the  incision  to  accom- 
plish removal.  Before  prolonging  the  incision  (best  done  with 
scissors),  a  sponge  is  placed  inside  the  abdomen  to  collect  any 
blood  that  may  escape.  The  bleeding  may  be  somewhat  free, 
but  it  is  easily  controlled  by  forci-pressure.  The  whole  length 
of  the  incision  will  be  from  three  to  five  inches.  There 
is  no  objection  to  making  a  second  incision  at  right  angles  to 


394  PYLORECTOMY. 

the  first,  if  the  subsequent  steps  of  the  operation  will  thereby 
be  facilitated. 

Isolation  of  the  Pylorus. — The  stomach  is  lifted  up  to  the  wound, 
and  the  growth  carefully  examined,  to  determine  the  amount  of 
tissue  which  has  to  be  removed.  The  great  omentum  is  first 
divided  close  to  the  greater  curvature,  and  over  as  little  area  as 
is  possible  consistently  with  complete  removal  of  the  growth. 
The  omentum  is  caught  up  in  successive  portions  between  pairs 
of  pressure  forceps,  and  divided  between  them.  Ligatures  are 
applied  behind  the  forceps  attached  to  the  omentum,  and  the 
forceps  are  removed.  Morris  suggests  that  "  double  ligatures 
may  be  passed  with  an  aneurism  needle  at  short  intervals 
through  the  portions  of  the  omentum  to  be  divided,  and  the 
section  made  after  the  ligatures  are  tightened."  The  same 
proceeding  is  carried  out  with  the  lesser  omentum.  Any  en- 
larged lymphatic  gland  may  now  be  removed.  If  the  pylorus 
is  low  down  and  adherent,  the  danger  of  wounding  the  trans- 
verse meso-colon,  and  so  causing  gangrene  of  the  bowel,  must 
be  borne  in  mind.  To  avoid  this  risk,  Lauenstein  has  made 
a  suggestion  to  peel  the  peritoneum  off  the  posterior  surface  of 
the  pylorus  ;  but  this  is  scarcely  advisable  in  malignant  disease. 

When  the  portion  to  be  removed  has  been  freed  from  its 
connections,  one  or  more  large  flat  sponges  are  placed  under  it, 
so  as  to  raise  it  up  through  the  parietal  opening.  Other  sponges 
are  packed  around,  covering  and  protecting  every  portion  of 
exposed  peritoneum,  and  so  rendering  the  operation  as  nearly 
extra-peritoneal  as  may  be. 

Resection  of  the  Diseased  Structures. — The  walls  of  the  stomach 
are  best  divided  by  successive  cuts  with  a  scissors.  Bleeding 
vessels  are  ligatured  as  they  are  divided.  The  direction  of  the 
incision  is  guided  by  the  shape  of  the  growth  :  but  the  mode  of 
its  completion  will  depend  on  where  it  is  intended  to  insert  the 
duodenum  into  the  divided  end  of  the  stomach.  If  there  is 
much  dilatation  of  the  stomach,  Wolfler's  advice,  to  insert  the 
duodenum  close  to  the  greater  curvature,  will  be  followed. 
In  this  case,  the  upper  section  of  the  stomach-walls  may  be  at 
once  sutured  before   completing  the  removal  of  the  diseased 


FIXING   DUODENUM   TO   STOMACH.  395 

mass.  In  his  later  operations  Billroth,  in  lessening  the  calibre 
of  the  divided  end  of  the  stomach  so  as  to  fit  the  small  opening 
of  the  duodenum,  does  not  divide  the  mucous  membrane  at  the 
end  of  the  incision,  but  removes  a  V-shaped  flap  composed  only 
of  peritoneum  and  muscular  coat.  The  edges  of  this  gap  are 
brought  together  by  stitches,  which  do  not  include  the  mucous 
membrane,  this  layer  being  bent  inwards  towards  the  cavity  of 
the  viscus.  Threads  placed  in  the  peritoneal  coats  prior  to 
complete  division  insure  that  there  is  no  rotation  of  stomach 
or  duodenum,  and  that  they  are  united  in  their  natural 
planes.  No  definite  instructions  applicable  to  every  case 
can  be  laid  down :  the  lines  of  division,  the  sites  of  appo- 
sition, and  the  mode  of  suturing,  must  be  decided  upon  by 
the  operator. 

When  the  stomach  is  opened,  any  extravasated  contents 
are  at  once  absorbed  by  a  sponge.  A  suitable  sponge  may  be 
temporarily  placed  in  the  duodenum. 

Sutimng  the  Duodenum  to  the  Stomach. — The  opening  of  the 
stomach  being  larger  than  that  of  the  duodenum,  two  sets  of 
sutures  will  be  necessary — one  for  uniting  the  duodenum  to  the 
stomach,  the  other  for  closing  the  opening  in  the  stomach 
itself.  Circumstances  must  determine  at  the  time  whether  it  is 
better  first  to  suture  the  superfluous  gap  in  the  stomach,  or  first 
to  insert  the  duodenum  into  the  space  retained  for  it.  Probably, 
in  most  cases,  part  of  each  proceeding  will  be  finished  before 
concluding  the  whole  of  either. 

Wolfler's  suggestion,  that  as  many  sutures  as  possible  be 
placed  from  the  inside,  is  a  valuable  one.  The  lips  of  the 
incision  are  inverted,  so  as  to  bring  peritoneal  surfaces  into 
contact,  and  the  first  rows  of  stitches  are  inserted  and  tied 
from  the  mucous  aspect.  As  the  openings  are  gradually  closed, 
it  will  become  less  easy  to  place  these  inner  sutures,  and  then 
the  double  row  must  be  inserted  from  without.  About  a  third 
or  more  of  the  suturing  may  be  done  partly  from  the  inside  and 
partly  from  the  outside ;  the  rest  must  be  done  entirely  from 
the  outside.  However  applied,  the  sutures  are  essentially  the 
Czerny-Lembert.     At    the   part   where   the   transverse   line   of 


396  PYLORECTOMY. 

sutures  in  the  duodenum  meets  the  longitudinal  line  in  the 
stomach,  a  few  extra  stitches  should  be  inserted. 

Nearly  all  operators  have  used  the  simple  interrupted 
suture.  Inserting  and  tying  a  double  row  of  these,  which 
must  be  very  numerous  —  from  forty  to  sixty,  —  necessarily 
occupies  a  great  deal  of  time.  I  can  see  no  objection  to  the 
employment  of  the  continuous  suture,  interrupted,  as  Pollock 
suggests,  after  every  four  or  five  stitches.  For  the  inner  row,  if 
inserted  from  the  mucous  aspect,  the  continuous  suture  would 
seem  to  be  particularly  suitable. 

Fine  Chinese  silk  is  the  favourite  suture-material :  catgut 
has  been  used :  but  there  is  danger  of  its  being  absorbed  before 
union  is  firm.  The  needles  now  proved  to  be  most  suitable  for 
this  and  similar  work  on  the  intestines  are  straight,  round 
milliner's  needles,  about  an  inch  in  length.  For  resection  of 
the  pylorus  some  thirty  or  forty  needles  should  be  provided. 

Ver}^  much  of  the  detail  must  be  decided  upon  at  the  time 
of  operation,  and  not  a  little  of  it  will  be  regulated  by  the 
habits  and  manipulative  peculiarities  of  the  surgeon.  Few 
surgeons  would  undertake  the  operation  without  having  per- 
formed it  several  times  on  the  dead  subject,  and  tested  the 
efficiency  of  the  suturing  by  injecting  fluid  into  the  stomach. 
More  may  be  learnt  in  this  way  than  by  a  great  deal  of 
reading. 

When  the  parts  have  been  satisfactorily  united,  the  sponges 
are  removed,  the  peritoneum  is  carefully  cleansed  around  the 
site  of  operation,  and  the  incision  in  the  parietes  is  closed  over 
a  sponge  in  the  ordinary  way. 

Aftev-treatment. — For  the  first  day  or  two,  or  longer  if  the 
patient's  strength  will  bear  it,  all  food  by  the  mouth  is  withheld, 
and  strength  is  supported  by  nutrient  enemas.  The  first 
nourishment  ought  to  be  peptonised  milk  or  soup  in  small 
quantities.  Meat  has  been  given  on  the  fifth  day  after  oper- 
ation ;  but  if  there  is  no  urgency,  it  is  wise  not  to  incur 
any  unnecessary  risk  by  premature  disturbance  of  the  gastric 
wounds. 


Gastro-enterostomy. 

This  operation  is  the  estabHshment  of  a  permanent  fistula 
between  the  stomach  and  some  part  of  the  small  intestine. 
Gastro-duodenostomy  means,  more  specifically,  the  making  of  a 
fistula  between  stomach  and  duodenum ;  gastro-jejunostom}^, 
between  stomach  and  jejunum. 

History. — Wolfler  of  Vienna  first  performed  the  operation  on 
September  27th,  1881.  He  began  with  the  intention  of  per- 
forming pylorectomy  for  cancer ;  and  finding  the  operation 
impracticable  on  account  of  adhesions  to  the  pancreas,  he 
performed  gastro-enterostomy.  The  patient  lived  four  months. 
Billroth  and  Lauenstein  followed,  each  with  one  case,  in  the 
same  year. 

Conditions  for  which  the  Operation  may  be  Performed. — -In  its 
original  conception,  gastro-enterostomy  was  intended  as  a 
substitute  for  pylorectomy  in  cases  where  that  operation  was 
impracticable.  In  some  cases,  however,  it  appeared  as  a  rival 
of  the  radical  proceeding.  Rydygier  and  Monastryski  per- 
formed gastro-enterostomy  for  cicatricial  stenosis,  and  here  it 
may  be  considered  as  a  substitute  for  divulsion. 

Generally  speaking,  gastro-duodenostomy  may  be  considered 
as  an  operation  possible  for  any  form  of  pyloric  obstruction, 
malignant  or  non-malignant.  In  non-malignant  stricture,  it 
ought  not  to  be  performed  until  dilatation  has  failed.  In  malig- 
nant stricture  it  may  be  regarded  both  as  a  rival  of,  and  as  a 
substitute  for,  pylorectomy.  As  being  a  less  serious  operation 
than  pylorectomy,  and  as  being  feasible  in  a  greater  number  of 
cases,  it  has  a  wider  field.  Even  in  cases  where  pylorectomy  is 
possible  it  may  be  argued  that  gastro-enterostomy,  by  giving  a 
greater  probable  chance  of  immediate  recovery  and  a  not  greatly 
diminished  likelihood  of  prolongation  of  life,  is  the  better 
operation  for  cancer  of  the  pylorus. 

Appreciation  and  Mortality. — We  have  not  sufficient  grounds 
on  which  to  base  conclusions  as  to  the  value  of  the  operation. 


398  GASTRO-ENTEROSTOMY. 

So  far  tlie  actual  results  have  not  been  quite  up  to  expectation. 
Winslow'''  collected  13  cases  of  operation,  of  which  9  died. 
Eight  operations  have  been  performed  in  Billroth's  Clinic,  with 
5  deaths.  The  longest  survival  after  operation  for  cancer  up  to 
date  was  in  a  case  operated  on  by  Barker  of  King's  College, 
London,  where  the  patient  lived  one  year  and  one  week. 
Rockwitzt  collected  22  cases.  Complete  cures  were  got  in  2 
cases  of  simple  stricture  ;  5  were  alive  at  periods  between  one 
and  seven  months  ;  4  recovered  from  the  operation,  but  died  in 
a  few  weeks;  in  the  remaining  11  (50  per  cent.)  the  operation 
greatly  hastened  the  patient's  death.  Since  Rockwitz  wrote, 
Postempski  of  Rome:]:  has  had  a  success;  and  Ransohoff§  has 
operated  successfully,  using  decalcified  bone  plates.  Mr.  H. 
Pagelj  has  collected  36  cases  (the  two  preceding  are  omitted  or 
overlooked),  of  which  20  recovered.  The  mortality  is  less  over 
its  first  cases  than  was  that  of  pylorectomy ;  but  still,  it  is  very 
large.  Five  died  of  collapse.  Two  died  of  kinking  of  the  bowel 
at  the  site  of  junction  to  the  stomach.  Haemorrhage,  peritonitis, 
and  exhaustion  are  among  the  other  causes  of  death. 

It  is  right  to  say  that  most  of  the  operations  have  been  per- 
formed under  conditions  less  favourable  than  pylorectomy  has 
had.  Probably  if  the  operation  were  performed  earlier,  it  would 
have  better  results.  As  it  offers  less  beneficent  results  than 
pylorectomy,  it  ought  under  similar  conditions  to  be  less  fatal. 
Time  alone  will  show  whether  it  will  be  so. 


THE    OPERATION. 

The  parietal  incision,  in  most  of  the  cases,  has  been  a  trans- 
verse or  slightly  oblique  one  along  the  free  margins  of  the  right 
ribs.  Barker,  however,^  in  his  very  successful  case  used  a  median 
incision  from  just  below  the  ensiform  cartilage  to  the  left  side  of 

*   Amei:    Jonni.   Med.  Sc,   April,   1885. 

t  Deutsche  Zeit.f.  Ghiv.,  June  22nd,  1887.  \  Sperimcntale,  August,  1887. 

§  Polyclinic,  Phila.,  Feb.,  1889. 

II  Meeting  Roy.  Med.  Chir.  Soc,  May  14th,  18S9. 

^f  Brit.  Med.  Jouvn.,  Feb.  13th,  1886. 


THE   OPERATION.  399 

the  umbilicus.     The  direction  of  the  incision  matters  little,  if 
sufficient  room  is  provided  for  manipulation. 

The  stomach  being  exposed  (it  will  have  been  previously 
cleansed  and  emptied),  a  suitable  piece  of  intestine  is  fixed  upon 
to  attach  to  the  stomach-wall.  Prime  regard  is  to  be  paid  to 
the  facility  with  which  the  bowel  can  be  co-aptated  to  the 
stomach,  and  not  so  much  to  the  physiological  importance  of 
having  the  junction  made  at  as  high  a  point  in  the  bowel  as 
possible.  It  will  rarely  be  easy,  without  unduly  dragging  on 
the  parts,  to  bring  any  part  of  the  duodenum  into  contact  with 
the  stomach  ;  and  the  same  may  be  said  of  the  first  six  inches 
or  so  of  the  jejunum.  If  the  great  omentum  is  torn  through, 
apposition  is  more  easily  effected  in  the  highest  part  of  the 
bowel.  But  as  two  deaths  already  have  occurred  from  kinking 
of  the  gut,  bringing  it  through  an  artificially  made  opening  in 
the  omentum  is  not  to  be  recommended.  The  whole  omentum, 
with  the  transverse  colon,  might  be  turned  upwards,  and  the 
posterior  surface  of  the  stomach  thus  exposed  might  be  united 
to  the  end  of  the  duodenum  or  the  beginning  of  the  jejunum. 
But  this  is  not  an  easy  proceeding.  Barker's  proceeding  of 
carrying  the  bowel  round  the  edge  of  the  omentum  seems  on 
the  whole  to  be  the  best — at  least,  where  the  omentum  is  not 
very  large. 

The  omentum  is  pushed  to  the  left,  and  the  first  part  of  the 
jejunum  is  caught  in  the  fingers  and  drawn  to  the  surface.  The 
middle  of  the  anterior  wall  of  the  stomach  is  also  drawn  out  of 
the  wound,  and  both  are  supported  by  packing  warm  carbolized 
sponges  around.  On  the  loop  of  intestine  two  spring  clamp- 
forceps,  such  as  Makins  used  for  resection  of  the  bowel,  may 
now  be  placed  about  three  inches  apart,  after  all  intestinal 
contents  have  been  gently  squeezed  out  between  them.  An 
assistant  holds  and  manipulates  the  bowel  by  means  of  these. 
Barker  used  two  pieces  of  rubber  tubing  carried  through  the 
mesentery  for  this  purpose.  The  gut  and  stomach  are  now  laid 
together  at  the  points  where  the  openings  are  to  be  made,  and  a 
longitudinal  fold  of  the  latter,  with  the  empty  bowel,  is  pinched 
up  between  the  finger  and  thumb.     An  incision  about  an  inch 


400  GASTRO-ENTEROSTOMY. 

and  a  half  long  is  made  in  the  wall  of  the  stomach,  and  a 
corresponding  one  in  the  approximated  gut.  This  incision  may 
be  made  completely  through  the  walls  of  the  viscera,  or,  accord- 
ing to  Barker's  excellent  plan,  only  through  the  serous  and 
muscular  coats.  By  this  method  the  most  important  part  of 
the  suturing  may  be  carried  out  before  the  stomach  or  bowel  is 
opened.  I  quote  his  words  :  "  Still  holding  the  parts,  as  before, 
between  finger  and  thumb,  I  now  united  the  posterior  edges  of 
the  wound  by  a  continuous  suture,  the  needle  entering  and 
emerging  in  each  case  between  nmcous  and  muscular  coats, 
and  the  threads  crossing  the  cut  edges  of  the  muscular  and 
serous  coats.  In  this  way  the  serous  surfaces  were  closely 
united  from  end  to  end  before  either  viscus  was  opened.  The 
row  of  stitches  (which  were  about  an  eighth  of  an  inch  apart) 
was  carried  about  a  quarter  of  an  inch  beyond  each  end  of  the 
incision  in  the  coats  of  the  bowel.  The  moment  had  now  come 
to  open  both  the  stomach  and  intestine  completely;  and  this 
was  done  with  a  stroke  of  the  scissors  through  the  mucous  coat 
in  each  case,  special  sponges  being  ready  to  receive  any  fluid 
which  might  escape.  After  careful  cleansing,  the  anterior 
borders  of  both  openings  were  now  united  by  a  row  of  inter- 
rupted fine  silk  sutures,  introduced  according  to  Czerny's 
method.  When  this  was  completed,  the  two  openings  were 
securely  closed ;  but,  as  an  extra  precaution,  the  intestine  was 
turned  over,  and  the  posterior  suture  was  reinforced  by  a  second 
row  of  interrupted  sutures,  placed  about  a  quarter  of  an  inch 
away  from  the  first.  The  anterior  row  was  then  similarly  rein- 
forced by  a  row  of  continuous  sutures,  taking  up,  as  before, 
only  the  serous  and  muscular  tunics."  This  description  I 
believe  to  represent  the  most  perfect  technique  of  the  operation 
which  has  yet  been  carried  out. 

It  would  be  wrong  to  conclude  a  description  of  the  mode  of 
performing  this  operation  without  referring  to  the  results  of  the 
highly  valuable  experiments  of  Senn  of  Milwaukee.*  These 
show  that  the  use  of  decalcified  and  perforated  bone  plates  are 
of  great  value  in  the  artificial  formation  of  intestinal  anas- 
*  Trans   Internat.  Med.  Congress,  vol.  i.,  p.  460 


INTESTINAL   ANASTOMOSIS.  401 

tomosis,  and  suggest  other  improvements,  which,  in  the  absence 
of  a  sufficient  number  of  operations  on  the  human  subject,  it 
would  be  out  of  place  here  to  fully  describe.  As,  however, 
from  the  highly  favourable  results  of  his  numerous  experiments, 
the  rapidity  with  which  the  operation  could  be  performed,  and 
the  palpable  soundness  of  the  physiological  processes,  it  would 
be  quite  proper  to  put  Senn's  method  in  practice  in  human 
beings,  I  shall  give  a  short  resume  of  his  method.  It  is  equally 
applicable  to  all  parts  of  the  intestinal  tract ;  the  operation — 
gastro-enterostomy,  jejuno-ileostomy,  ileo-ileostomy,  ileo-colos- 
tomy,  colo-colostomy — whatever  it  may  anatomically  be,  is 
practically  the  same. 

After  shutting  off  the  general  lumen  from  the  part  to  be 
operated  upon,  two  longitudinal  incisions  are  made  through  the 
walls  of  the  viscera  to  be  approximated.  The  best  incision  is  a 
longitudinal  one  on  the  convex  aspect  of  the  bowel  most  dis- 
tant from  the  mesenter}',  the  length  in  dogs  being  from  an  inch 
and  a-half  to  two  inches,  corresponding  to  one  from  two  to  two 
and  a-half  inches  in  human  beings.  The  stomachic  incision,  if 
the  operation  is  gastro-enterostomy,  is  of  equal  length :  through 
the  two  incisions  oval-shaped  perforated  decalcified  bone  plates, 
with  four  threads  attached,  one  thread  near  to  each  end  of 
the  oval ;  the  other  two  at  the  sides  of  the  perforation.  The 
lateral  threads  perforate  all  the  coats  of  the  bowel.  (Fig.  52.) 
Silk  was  the  material  preferred  for  the  threads.  The  two  plates 
were  approximated  b}'  tying  the  threads,  the  knots  being  buried 
between  the  serous  surfaces.  The  plates  then  held  fir-mly  in 
contact  and  at  perfect  rest  two  large  areas  of  serous  s^irface, 
which  quickly  became  agglutinated  and  united  by  organised 
tissue.  The  decalcified  plates  soon  broke  up  or  dissolved  in  the 
stomachic  and  intestinal  fluids,  and  the  opening  was  established. 
The  perforations  in  the  plates  in  the  meanwhile  prevented  danger 
from  intestinal  obstruction. 

The  directions  given  for  preparing  the  bone  plates  are  as 
follows.  It  must  be  remembered  that  these  were  for  emploj'ment 
in  dogs,  and  that  they  must  be  of  greater  size  for  use  in  the 
human  subject.     "  The  compact  layer  of  an  ox's  femur  or  tibia 

27 


402 


GASTRO-ENTEROSTOMY. 


is  cut  with  a  fine  saw  into  oval  plates  one-fourth  of  an  inch  in 
thickness,  two  and  one-half  to  three  inches  in  length,  and  an 
inch  in  width.  The  plates  are  then  decalcified  in  a  ten  per  cent, 
solution  of  hydrochloric  acid,  changed  every  twenty-four  hours 
until  they  have  become  sufficiently  soft,  and  can  be  bent  in  any 
direction   without   fracturing.      After   decalcification,  they  are 


Fig.  52. 


Diagram  shonnng  the  employment  of  perforated  bone-plates  in 

the  formation  of  Intestinal  Anastomosis.     The  dotted 

outlines  shotv  the  limits  of  the  plates. 

washed  by  letting  water  flow  over  them  from  three  to  six  hours, 
so  as  to  remove  the  acid.  The  plates  are  then  covered  with 
porous  paper,  and  compressed  between  thin  pieces  of  tin  until 
they  are  perfectly  dry.  If,  during  the  process  of  drying,  the 
plates  are  not  compressed  between  two  smooth  surfaces,  they 
become  disturbed  by  warping.  The  hardened  plates  are  next 
drilled  several  times  in  a  straight  line  in  the  centre,  and  the 
openings  enlarged  and  connected  with  a  file  until  the  opening  is 
five-eighths  of  an  inch  in  length,  and  about  one-eighth  to  one- 


DUODEN  OSTOMY.  403 

sixth  of  an  inch  in  width.  The  sharp  margins  of  the  plate  and 
perforation  are  removed  with  a  file.  With  a  fine  drill  four  per- 
forations for  the  sutures  are  made  near  the  margins  of  the  oblong 
perforation — one  at  each  end,  and  one  at  each  side.  For  preser- 
vation, the  plates  are  kept  in  absolute  alcohol.  When  the  plates 
are  to  be  used  they  are  washed  in  a  two  per  cent,  solution  of 
carbolic  acid,  and  the  threads  or  sutures  attached  by  threading 
two  fine  sewing  needles  each  with  a  piece  of  aseptic  silk  twenty- 
four  inches  in  length,  which  are  tied  together."  The  needles 
are  used  to  perforate  the  walls  of  the  viscus  at  the  margins  of 
the  opening,  and  the  plates  are  approximated  and  tied.  For 
further  details,  the  reader  is  referred  to  Senn's  report.  In  the 
meantime,  the  educated  surgeon  will  be  prepared  tO  apply  his 
knowledge  in  any  suitable  case ;  and  it  will  be  proper  that  he 
should  approach  any  case  in  which  the  formation  of  intestinal 
anastomosis  may  be  contemplated  with  an  assorted  supply  of 
perforated  bone  plates  preserved  in  alcohol. 

The  abdomen  is  cleansed  and  the  parietal  wound  closed  in 
the  ordinary  way.  The  after-treatment  need  in  no  way  differ 
from  that  of  other  operations  upon  the  stomach. 

Duodenostoniy. — This  is  the  establishment  of  a  duodenal  fistula 
through  which  nourishment  is  passed  into  the  bowel.  It  is  per- 
formed as  a  mode  of  relief  in  cases  of  pyloric  stenosis,  under 
circumstances  similar  to  those  for  which  gastro-enterostomy  is 
carried  out.  The  operation  has  not  been  done  often.  Langen- 
buch  of  Berlin  performed  the  first  operation,  in  1879;  and 
Robertson,  Southam,  and  a  few  others  have  operated  in  recent 
years.  None  of  the  reported  cases  have  recovered.  Two  of 
them  have  been  performed  for  cicatricial  stenosis,  and  would 
probably  have  been  better  treated  by  forcible  dilatation. 

The  operation  is  found  practically  not  to  be  so  difficult  as 
might  be  expected.  In  health,  it  would  scarcely  be  possible  to 
bring  the  duodenum  up  to  the  abdominal  wound  ;  but,  in  disease, 
the  attachments  of  the  duodenum  are  stretched,  and  the  bowel 
is  usually  displaced  downwards  with  the  dilated  stomach,  so 
that  it  can  without  much  difficulty  be  brought  to  the  surface. 
Langenbuch   and   Southam    performed   the  operation   in   two 

27  * 


404  JEJUNOSTOMY. 

stages — postponing  the  opening  of  the  bowel  for  seven  and 
three  days  respectively.  The  principles  of  operation  are  essen- 
tially the  same  as  in  gastrostomy  for  stricture  of  the  oesophagus, 
and  need  not  be  again  repeated. 

Jejunostomy. — This  is  the  same  proceeding  as  duodenostoni)^, 
carried  out  for  a  similar  purpose,  onl}'  a  little  lower  down  in  the 
bowel,  where  it  is  less  closely  attached  and  more  easily  drawn 
to  the  surface.  Pearce  Gould,  Golding-Bird,  Ogston,  and 
others  have  performed  the  operation  in  England.  Ogston's 
case  was  ver}'^  successful ;  the  others  were  failures.  A  few 
scattered  cases  are  recorded ;  but  the  operation  is  still  in  its 
infancy,  and  little  can  be  said  about  it.  It  seems  theoretically 
to  be  a  better  operation  than  duodenostomy,  as  regards  facility 
of  performance  :  as  regards  the  worth  of  it,  as  offering  an 
opening  for  the  supply  of  food,  there  is  probably  little  to  choose 
between  them. 

If  in  any  case  in  which  pylorectomy  was  contemplated,  and 
found,  after  making  the  parietal  incision,  to  be  impracticable,  it 
is  still  considered  advisable  to  give  the  patient  a  chance  of 
prolongation  of  life,  then  I  believe  that  the  choice  lies  between 
gastro-enterostomy  and  jejunostomy.  If  the  patient  is  fairly 
strong  and  is  bearing  the  operation  well,  gastro-enterostomy 
might  be  selected ;  if  it  appears  advisable  to  shorten  the  pro- 
ceeding as  much  as  possible,  jejunostomy  is  substituted. 

The  operation  requires  no  special  description.  The  jejunum 
may  be  found  by  pushing  aside  the  omentum,  and  is  drawn  to 
the  surface,  sutured  to  the  abdominal  wall  and  opened,  either  at 
once  or  later  on,  as  in  gastrostomy.  The  value  of  peptonised 
foods  in  the  subsequent  treatment  of  the  case  is  likely  to  be 
conspicuous. 

Gastrectomy,  or  total  extirpation  of  the  stomaceh,  was  begun 

in  1883  by  Connor  of  Cincinnati,*   but  was  not  completed,  as 

the  patient  died  on  the  table.     He  intended,  after  removing  the 

stomach,  to  unite  the  cardia  to  some  part  of  the  small  intestine. 

*  Phila.  Med.  News,  Nov.  22nd,  1884. 


GASTRECTOMY.  405 

He  says  nothing  as  to  how  the  vitaHty  of  the  colon  is  to  be 
provided  for,  and  produces  insufficient  evidence  to  show  that 
the  operation  is  either  feasible  or  proper. 

Partial  Gastrectomy,  for  cases  where  a  malignant  growth  is 
situated  in  the  walls  of  the  stomach  away  from  the  pylorus  or 
cardia,  would  seem  to  be  a  proceeding  easier  than  pylorectomy, 
and  likely  to  be  followed  by  greater  success.  So  far  as  I  know, 
the  operation  has  not  yet  been  performed. 

Intubation  of  the  Pylorus,  for  stenosis,  has  been  carried  out  by 
Hahn  of  Berlin.  He  performed  gastrostomy,  then  carried  a  tube 
through  the  stenosed  pylorus  into  the  duodenum,  and  left  it 
there.  The  patient  lived  three  weeks.  Forcible  dilatation  would 
now,  in  all  probability,  be  preferably  adopted. 


Section  VII 


OPERATIONS    ON     THE     INTESTINES. 


SURGICAL  AND  TOPOGRAPHICAL  ANATOMY. 

There  is  no  definite  topography  of  the  small  intestines,  except 
at  their  extremities.  Treves*  as  a  result  of  careful  examina- 
tions in  one  hundred  bodies,  came  to  the  conclusion  that  accu- 
rate localisation  was  quite  impossible.  In  the  majority  of  adult 
bodies  the  following  arrangement  was  found  :  "  The  small  in- 
testine is  disposed  in  an  irregularly  curved  manner  from  left  to 
right.  The  gut,  starting  from  the  duodenum,  will  first  occupy 
the  contiguous  parts  of  the  left  side  of  the  epigastric  and 
umbilical  regions ;  the  coils  then  fill  some  part  of  the  left 
hypochondriac  and  umbilical  regions ;  they  now  commonly 
descend  into  the  pelvis,  reappear  in  the  left  iliac  quarter,  and 
then  occupy  in  order  the  hypogastric,  lower  umbilical,  right 
*  The  Anatomy  of  the  Intestinal  Canal  and  Peritoneum  in  Man.  Lond.,  1885. 


SURGICAL  ANATOMY.  407 

lumbar,    and   right    iliac   regions.     Before   reaching   the  latter 
situation  they  commonly  descend  again  into  the  pelvis." 

Special  interest  attaches  to  a  knowledge  of  the  parts  of  bowel 
which  usually  occupy  the  pelvis.  It  is  not  till  some  three  or 
four  years  after  birth  that  the  pelvis  begins  to  accommodate 
intestine.  According  to  Treves,  the  parts  usually  found  in  the 
pelvis  of  an  adult  "belong  to  the  terminal  point  of  the  ileum, 
and  to  that  part  of  the  intestine  which  has  the  longest  mesen- 
tery— the  part,  namely,  which  extends  between  two  points, 
respectively  six  and  eleven  feet  from  the  end  of  the  duodenum. 
It  is  not,  therefore,  uncommon  to  find  loops  lying  together  in 
contact  with  the  pelvic  floor  that  are  in  reality  some  twelve  or 
fourteen  feet  apart." 

An  examination  of  some  twenty  bodies,  with  a  view  to  fixing 
the  topography  of  the  bowels,  convinced  the  writer  that  the 
variations  were  too  great  to  be  of  value  in  practical  surgery. 
The  average  disposition,  as  described  by  Treves,  though  for  the 
majority  of  cases  probably  correct,  is  yet  liable  to  so  many 
variations  in  individuals,  that  rules  of  practice  cannot  with 
safety  be  based  upon  it. 

The  attachments  of  the  mesentery  have  some  surgical 
importance.  (Fig.  53.)  In  localising  a  certain  portion  of  bowel, 
and  ascertaining  the  direction  of  it  from  duodenum  to  caecum, 
it  may  be  of  assistance  to  remember  that  the  right  layer  of  the 
mesentery  is  also  its  upper  layer,  and  the  left  layer  the  lower. 
The  upper  layer  is  continuous  with  the  lower  layer  of  the  trans- 
verse meso-colon,  and  also  with  the  peritoneum  which  invests 
the  ascending  colon.  The  lower  layer  is  continued  over  the 
descending  colon,  forms  the  mesentery  of  the  sigmoid  flexure, 
and  descends  into  the  pelvis.  When  the  abdomen  is  not  dis- 
tended, the  length  of  the  mesentery  is  such  that  any  part  of  the 
small  intestine  can  easily  be  raised  up  through  an  opening  in 
the  abdominal  wall  near  the  umbilicus.  When  the  abdomen  is 
distended,  it  may  be  impossible  to  bring  certain  portions  of 
bowel  through  a  median  incision.  Normally,  according  to 
Treves,  the  bowel  cannot  be  dragged  down  below  the  level  of 
the  spine  of  the  pubes.     In  elderly  women  with  lax  parietes  the 


408 


OPERATIONS   OF   THE  INTESTINES. 


Fig  53-     (Gray's  Anatomy,     nth  Ed. 


Diagram  devised  by  Dr.    DeUpine   to  show  the  lines  along  zchich  the  Peritoneum 
leaves  the  Wall  of  the  Abdometi  to  invest  the  Viscera. 


I.  Peritoneum.  2.  Extra-peritoneal  Tissue.  3.  Diaphragmatic  end  of  Gastro-hepatic 
Omentum.  4.  Gastro-piirenic  Ligament.  5.  Gastro-splenic  Omentum.  6.  Foramen  of 
Winslow.  7.  Duodenum  (ist  part).  8.  Costo-colic  Ligament.  9.  Dot  between  two  Anterior 
Layers  01  Great  Omentum.  10.  Transverse  Meso-colon.  11.  Bare  surface  for  Descending 
Colon.  12.  The  two  layers  of  the  Mesentery  Proper.  13  Bare  surface  for  Ascending  Colon. 
14.  Sigmoid  Meso-colon.  15.  Bare  Surface  for  Caecum.  16.  Meso-rectum.  17.  Bare  surface 
for  2nd  part  of  Rectum.  18.  Left  Lateral  False  Ligament  cf  Bladder.  19.  Vena  Cava  Inferior. 
20.  CEsophagus.  21.  Right  Phrenic  Artery.  22.  Coronary  Artery.  23.  Hepatic  Artery. 
24.  Splenic  Artery.  25.  Pancreas.  26.  Inferior  Pancreatico-duodenal  Artery.  27.  Colica  Media. 
28.  Superior  Mesenteric.  29.  Duodenum  (3rd  part).  30.  Aorta.  31.  Duodenum  (2nd  part). 
32.  Right  and  Left  Kidneys.  33.  Superior  Mesenteric.  34.  Aorta.  35.  Colica  Sinistra. 
36.  Colica  Dextra.  37.  Vasa  Intestini.  38.  Sigmoid  Artery.  39.  Sup.  Haemorrhoidal  Artery. 
40.  Common  Iliac  Artery.  41.  Internal  Iliac  Artery.  42.  External  Iliac  Artery.  43.  Epigastric 
Artery.  44.  Bladder.  45.  Right  Lateral  Ligament  of  Liver.  46.  Falciform  Ligament  of 
Liver.    47.  Left  Lateral  Ligament  of  Liver. 


SURGICAL   ANATOMY.  409 

mesentery  is  long,  and  the  bowels  are  permitted  greater  freedom 
of  range. 

The  topography  of  the  large  bowel  is  more  definite.  With 
respect  to  the  caecum,  Treves's  investigations  have  shown  the 
existence  of  very  general  misconception.^'  It  is  generally  held 
that  the  posterior  surface  of  the  caecum  is  uncovered  by  peri- 
toneum, and  is  attached  by  areolar  tissue  to  the  iliac  fascia,  thus 
bespeaking  the  existence  of  a  meso-caecum.  Treves  found,  on 
the  contrary,  that  the  caecum  was  always  entirely  enveloped  by 
peritoneum,  and  lay  free  in  the  abdominal  cavity ;  that  there 
was  no  sign  of  a  meso-caecum  ;  and  that  it  usually  lay  upon  the 
psoas  muscle,  so  placed  that  its  lowest  point  projected  beyond  the 
inner  border  of  that  muscle.  In  the  great  majority  of  instances, 
the  apex  of  the  caecum  will  be  found  to  correspond  with  a  point 
a  little  to  the  inner  side  of  the  middle  of  Poupart's  ligament. 
The  lower  limit  of  the  reflexion  of  the  peritoneum  from  the  under 
surface  of  the  caecum  to  the  posterior  surface  of  the  abdominal 
wall — in  other  words,  the  lower  border  of  the  ascending  meso- 
colon is  a  little  below  the  level  of  the  superior  crest  of  the  ilium. 

The  direction  of  the  ascending  and  the  descending  colon  is 
vertical,  and  the  transverse  colon  lies  almost  horizontally 
between  them.  The  splenic  flexure  is  higher  than  the  hepatic, 
and  lies  deeper  in  the  abdomen.  And  the  transverse  colon  very 
frequently  takes  a  bend  downwards.  These  bends  sometimes 
descend  a  considerable  distance,  occasionally  reaching  the 
pubes ;  but  they  rarely  get  below  the  level  of  the  crests  of  the 
ilia.    They  are  sometimes  quite  acute,  forming  V-shaped  curves. 

Of  much  surgical  importance  is  the  disposition  of  the  ascend- 
ing and  descending  meso-colon.  It  is  generally  supposed  that  a 
meso-colon  is  more  common  on  the  right  side  than  on  the  left, 
and  this  is  often  quoted  as  an  argument  in  favour  of  left  lumbar 

*  Although  it  has  very  recently  been  shown  (Matas,  in  New  Orleans  Med. 
and  Surg.  Journal,  Dec,  1887)  that  twenty-five  years  before  Treves  wrote, 
Bardeleben  and  Luschka  insisted  on  the  fact  that  the  ca:cum  is  completely 
surrounded  by  peritoneum,  and  several  German  anatomists  maintained  the 
same  view,  I  have  preferred  to  leave  the  text  as  it  was  printed  in  the  first 
edition,  if  only  to  show  that,  so  far  as  we  in  England  have  been  instructed, 
Treves's  studies  deserve  to  be  considered  as  discoveries. 


410  OPERATIONS  ON  THE  INTESTINES. 

colotomy.  Treves  found  the  reverse  to  be  the  case.  "In  fifty- 
two  (out  of  a  hundred)  bodies  there  was  neither  an  ascending 
nor  a  descending  meso-colon.  In  twenty-two  there  was  a 
descending  meso-colon,  but  no  trace  of  a  corresponding  fold  on 
the  other  side.  In  fourteen  subjects  there  was  a  meso-colon  to 
both  the  ascending  and  the  descending  segments  of  the  bowel ; 
while,  in  the  remaining  twelve  bodies,  there  was  an  ascending 
meso-colon,  but  no  corresponding  fold  on  the  left  side.  It 
follows,  therefore,  that  in  performing  lumbar  colotomy  a  meso- 
colon may  be  expected  upon  the  left  side  in  36  per  cent,  of  all 
cases,  and  on  the  right  side  in  26  per  cent." 

It  may  perhaps  be  right  to  remark,  that  some  indefiniteness 
must  be  admitted  as  to  the  existence  or  not  of  an  ascending  or 
descending  meso-colon.  A  collapsed  gut  may  have  a  well- 
marked  meso-colon,  when  a  distended  gut  would  have  none. 
As  the  bowel  empties,  the  peritoneal  layers  fall  together  behind 
it ;  while,  as  it  is  filled,  they  are  pushed  apart,  and  the  intestine 
becomes  sessile.  It  will  be  found  that  a  dilating  colon  borrows 
more  of  its  investing  peritoneum  from  behind,  where  the  areolar 
tissue  is  lax,  than  from  the  front,  where  it  is  more  firmly 
adherent. 

The  left  meso-colon  is  usually  attached  along  the  outer 
border  of  the  kidney,  and  is  vertical.  The  right  meso-colon 
is  not  quite  vertical,  but  "  crosses  the  lower  end  of  the  kidney 
from  right  to  left,  and  then  ascends  along  the  inner  border  of 
the  gland  "  (Treves). 

In  surgical  operations  on  the  intestines,  it  is  impossible  to 
ignore  the  great  omentum.  Rarely  is  it  found  conforming  to 
the  anatomical  descriptions  of  it — spread  out  like  an  apron  over 
the  bowels.  In  many  cases  it  is  never  seen,  being  placed  high 
up,  coiled  or  folded  upon  itself.  In  other  cases  it  lies  entirely 
on  one  side  of  the  abdomen,  usually  the  left.  It  may  be  twisted 
up  like  a  rope,  or  spread  out  in  one  part  and  contracted  in 
another  ;  frequently  it  is  adherent  to  bowel  or  parietes  ;  some- 
times it  is  partly  embedded  among  the  intestines.  It  may  be 
thin  and  translucent  or  even  cribriform,  or  it  may  be  very  thick 
and  laden  with  fat. 


SURGICAL   ANATOMY.  411 

The  free  anastomosis  of  the  intestinal  vessels  in  the  peri- 
toneum has  as  much  surgical  significance  on  the  one  hand,  as 
their  circular  distribution  in  the  intestinal  walls  on  the  other. 
Thus,  though  a  piece  of  mesentery  may  be  destroyed  at  a  little 
distance  from  the  bowel  without  impairing  its  vitality,  the 
smallest  portion  of  bowel  left  without  its  mesentery  closely 
attached  to  it  may,  and  probably  will,  die. 

A  word  must  be  said  on  the  sigmoid  flexure  of  the  colon. 
Treves  has  shown  that  the  curve  which  this  part  of  the  bowel 
describes  is  more  of  the  shape  of  the  Greek  Q  than  the  letter  S. 
This  omega-flexure  has  a  well-marked  mesentery.  It  usually 
lies  wholly  in  the  pelvis.  When  distended  it  rises  out  of  the 
pelvis,  reaching  sometimes  as  high  as  the  umbilicus,  and,  in 
cases  of  extreme  distension,  even  to  the  liver.  In  this  condition 
it  is  liable  to  become  twisted  upon  itself,  producing  volvulus. 
Its  more  exact  disposition  does  not  here  specially  concern  us. 

As  bearing  upon  all  operations  on  the  intestines,  and  espe- 
cially on  resection  and  suture,  the  anatomical  structure  of  the 
intestinal  coats  and  the  mode  of  attachment  of  the  tube  to  the 
mesentery  are  of  supreme  importance.  The  following  state- 
ments are  based  upon  the  elaborate  studies  of  William  S. 
Halsted  of  New  York;*  also  upon  notes  by  Mr.  Anderson  of 
St.  Thomas's  Hospital,!  and  upon  some  observations  made  by 
myself.  As  they,  in  some  respects,  modify  or  contradict  generally 
accepted  views,  they  must  be  given  with  some  degree  of  fulness. 

Firstly,  as  to  the  structure  of  the  internal  coats.  Fig.  54  is 
copied  from  Halsted's  paper.  It  "is  a  diagram  of  the  dog's 
intestine,  and  is  intended  to  represent  accurately  the  thickness 
of  the  several  coats.  The  serosa  is  prolonged  beyond  the  outer 
muscular  coat  to  emphasise  its  thinness.  Between  the  sub- 
mucosa  and  the  glands  of  Lieberkiihn — in  other  words,  between 
it  and  the  lumen  of  the  intestine — practically  nothing  intervenes; 
and,  literally,  nothing  but  the  two  layers  of  muscularis  mucosae 
and  fibrosa  mucosae  respectively.  Fully  two-thirds  of  the  thick- 
ness of  the  wall  of  the  intestine  is  mucous  membrane.     When 

*  Internat.  Journ.  Med.  Sc,  Oct.,  1887. 
t  MacCormac's  Abdominal  Section,  1887,  p.  25. 


412 


OPERATIONS   ON  THE  INTESTINES. 


TUM  f" 


the  needle,  therefore,  has  been  passed  through  its  outer  third  it 
must  have  entered  the  glands  of  Lieberkiihn,  and,  hence,  the 
lumen  of  the  gut.  It  is  an  easy  matter  to  isolate  the  sub-mucosa. 
The  outer  muscular  coats  strip  from  it  readily,  and  the  mucous 
membrane  can  be  rapidly  scraped  off  with  a  knife.  Thus 
obtained,  the  sub-mucosa  is  found  to  be  an  exceedingly  tough 
fibrous  membrane.  It  is  air-tight  and  water-tight,  and  is  the 
*  skin  '  in  which  sausage-meat  is  stuffed.  It  is,  moreover,  the 
coat  of  the  intestine  from  which  '  catgut '  is  made. 

"A  needle,  on  being  pushed  vertically  through  the  walls  of  the 
intestine,  meets  with  considerable  resistance  when  it  reaches  the 

sub  -  mucosa,  and 
still  greater  re- 
sistance is  en- 
countered if  it  be 
attempted  to  pass 
the  needle  hori- 
zontally through 
its  meshes.  A 
delicate  thread  of 
this  tissue  is  very 
much  stronger  and 
better  able  to  hold 
a  stitch  than  a 
coarse  shred  of  the 
entire  thickness 
of  the  muscular 
and  serous  coats." 
Practical  experiments  to  test  this  point  bore  out  these  views. 
Halsted  "  soon  discovered  that,  even  to  the  sharpened  end  of  a 
needle,  sufficient  resistance  is  offered  by  the  sub-mucosa  to  be 
readily  appreciable,  and  that  it  is  possible  and,  with  very  little 
practice,  not  difficult  to  pick  up  at  each  stitch  a  thread-like 
piece  of  sub-mucosa  without  incurring  the  danger  of  passing 
into  the  lumen  of  the  gut." 

Practical  advantage  of  the  toughness  of  this  sub-mucosa  may 
furthcx  be  taken  by  picking  up  portions  of  it  in  stitches,  carefully 


-vM 


Fig.  54. 
Diagram  of  Section  of  Dog's  Intestine. 

P,  Peritoneum ;  L,  Longitudinal  Muscular  Coat ;  C,  Cir- 
cular Muscular  Coat;  S,  Sub-mucosa;  mm,  Muscularis, 
mucosae ;  L,  Glands  of  Lieberkiihn. 


SURGICAL   ANATOMY.  413 

placed  so  as  to  pierce  it  some  distance  apart,  and  making 
traction  on  the  sutures.  This  raises  a  ridge  on  the  serous 
aspect  of  the  gut,  which  at  once  marks  the  line  in  which  the 
co-aptating  sutures  should  be  placed,  and  by  raising  the  tissue  to 
the  needle,  greatly  facilitates  the  introduction  of  the  individual 
sutures.  I  have  endeavoured  to  show  this  in  the  diagram 
accompanying  the  description  of  enterorraphy. 

As  to  the  disposition  of  the  mesentery  around  the  gut,  we 
must  not  forget  that  it  is  not  a  complete  envelope,  but  leaves  a 
portion  of  the  lumen,  averaging  about  five-sixteenths  of  an  inch 
in  width  (Anderson),  for  which  the  outer  covering  is  the  mus- 
cular. The  divergence  of  the  layers  of  mesentery  begins  at  a 
distance  varying  from  two-thirds  to  three-fourths  of  an  inch 
from  the  wall  of  the  gut,  and  we  thus  get  a  triangular  space, 
filled  with  fat,  intestinal  vessels  and  lymphatics,  bounded  by 
mesentery  on  two  sides  and  bowel  on  the  third.  The  arterial 
loops  to  supply  the  intestines  lying  in  this  space  come  to  within 
a  third  of  an  inch  of  the  gut,  closer  in  the  lower  portion  of  the 
ileum  than  in  the  jejunum.  From  these  loops  ane  given  off  the 
straight  vessels,  which  pass  directly,  on  each  side  of  the  inter- 
space, to  supply  the  bowel.  It  is  evident  that  the  anastomosing 
loops  should  be  injured  as  little  as  possible,  if  the  vitality  of  the 
bowel  is  to  be  assured ;  triangular  resection  of  the  mesentery 
should  therefore  be,  as  far  as  possible,  avoided.  The  layers  of 
the  mesentery  at  their  attachment  to  the  bowel  are  very  lax  and 
easily  drawn  together  by  purse-string  sutures,  so  that  they  need 
not  be  in  the  way,  even  if  they  are  left  behind  ;  while,  as  will  be 
pointed  out  further  on,  they  may  be  employed  to  give  breadth 
and  solidity  to  the  intestinal  union  at  a  point  where  it  has  been 
found  that  it  most  frequently  gives  wa}'. 


Laparotomy  for  Intestinal  Obstruction. 

The  relief  of  intestinal  obstruction  by  Laparotomy  is,  in 
most  cases,  of  the  nature  of  a  herniotomy.  If  we  regard  an 
ordinary  hernial  sac  as  an  artificial  diverticulum  of  the  ab- 
dominal cavity,  and  if  the  sac  is  opened  during  operation,  we 
may  regard  such  as  an  abdominal  section.  In  intestinal  hernia 
we  operate  without  full  knowledge  of  the  site  and  nature  of  the 
obstruction ;  it  is  not  visible,  very  rarely  tangible,  and,  in  many 
cases,  can  only  be  inferred  with  a  high  degree  of  probability 
from  rational  symptoms. 

History. — The  question  of  operative  treatment  in  intestinal 
obstruction  has  been  discussed  for  centuries.  It  is  doubtful  if 
the  Greeks  or  Romans  performed  the  operation.  Le  Clerc,  in 
his  History  of  Medicine,  tells  us  that  Praxagoras  advised  lapar- 
otomy in  cases  of  volvulus  *  or  intussusception  ;  and  even 
incision  into  the  gut  to  allow  the  faeces  to  escape,  when  the  gut 
should  be  sewn  up  and  the  abdominal  wound  closed.  This  is 
certainly  very  advanced  treatment ;  but  it  is  more  than 
doubtful  if  it  was  ever  carried  out.  Praxagoras  was  very 
fond  of  the  use  of  emetics  in  intestinal  obstruction :  they  did 
good,  no  doubt,  by  relieving  the  distended  viscera  of  fluids  and 
gas,  just  as  Kussmaul's  treatment  does  by  the  repeated  use  of 
the  stomach-pump.  The  injection  of  air  per  anum  had  been  in 
use  since  the  days  of  Hippocrates.  In  later  times  bleeding  was, 
of  course,  in  constant  requisition. 

In  more  recent  times,  Bonet,  who  edited  Barbette's  work, 
writes  a  foot-note  to  his  remarks  on  volvulus,  that  he  has  known 
an  operation  performed  for  volvulus  with  success.     I  find  the 

*  Up  till  comparatively  recent  times  the  term  Volvulus  was  made  to 
include  all  varieties  of  Intestinal  Obstruction.  The  word  is  simply  the  Latin 
equivalent  of  the  Greek  ejAeJs  :  the  iliac,  rolling  or  twisting  passion,  also 
known  as  "  miserere  mei."  The  word  has  a  purely  subjective  meaning,  and 
has  no  relation  to  pathological  anatomy.  The  giving  of  an  anatomical 
significance  to  the  word  "volvulus"  is  simply  an  example  of  the  legion  of 
modern  medical  linguistic  barbarisms. 


■HISTORY.  415 

note  quoted  by  M.  Hevin,  in  a  paper  on  "  Gastrotomy  "  in  the 
Transactions  of  the  Royal  Academy  of  Surgery  of  Paris,  vol.  4,  1768  : 
"  The  baroness  de  Lanti,  of  Chatillon-sur-Seine,  was  nearly 
dead  of  an  iliac  passion.  A  young  surgeon  who  had  served  in 
the  army  for  a  long  time  came  forward,  and  promised  recovery 
if  the  patient  would  submit  to  operation.  He  was  allowed  to 
operate.  He  pulled  out  a  great  deal  of  the  intestine  before  he 
found  the  twist ;  he  freed  it,  nodos  dissolvit,  and  returned  it  to  its 
place.  He  sewed  up  the  abdomen,  and  the  wound  healed  nicely, 
and  the  patient  recovered."  The  Baroness  very  properly  settled 
a  pension  on  this  daring  young  surgeon,  but  he  did  not  live  long 
to  enjoy  it.  Hevin  considers  that  this  may  have  been  a  case  of 
hernia ;  but  it  is  difficult  to  see  why  he  should  have  to  undo 
twists,  and  stitch  up  the  abdominal  wall,  for  a  herniotomy.  No 
doubt  can  be  cast  on  another  case,  recorded  by  Oesterdykins 
Schacht,  in  which  Nuck  was  the  counsellor  of  operation.  In 
this  case  the  exposed  intestines  were  carefully  covered  by  warm 
milk  while  the  coils  were  unravelled,  and  the  patient  also 
recovered.  Most  authors  of  the  seventeenth  and  eighteenth 
centuries,  with  the  notable  exceptions  of  Hoffman  and  Felix 
Platerus,  condemn  the  operation.  Van  Sweiten  has  been 
quoted  as  being  favourable  to  Barbette's  operation,  and  other 
names  might  be  added.  No  doubt  the  operation  was  many 
times  performed  in  the  last  two  centuries,  but  with  almost 
uniform  failure ;  and  this  may  have  prevented  the  operators, 
in  the  face  of  the  very  general  condemnation  which  it  received 
at  the  hands  of  the  greatest  men,  from  publishing  their  cases. 
M.  Hevin  himself,  in  the  article  quoted,  is  by  no  means  in 
favour  of  operative  proceeding. 

In  the  surgery  of  the  present  century,  up  to  comparatively 
recent  times,  the  operation  had  no  history.  It  was  either  con- 
demned or  ignored.  And  even  at  the  present  day,  in  spite  of 
the  great  advances  in  abdominal  surgery  and  the  increased 
certitude  of  diagnosis,  there  are  many  medical  men  who  would 
consider  it  no  discredit  to  stand  by  with  folded  hands  while  a 
patient  is  dying  of  an  unrelieved  internal  strangulation  of  the 
bowels. 


416  LAPAROTOMY  FOR   OBSTRUCTION. 


CONDITIONS    FOR    WHICH    OPERATION    MAY    BE    PERFORMED. 

A  full  account  of  these  conditions  involves  a  description  of 
all  the  forms  of  intestinal  obstruction,  with  their  differential  and 
general  diagnosis.  The  limits  set  to  this  work  demand  that 
such  description  be  ver}^  short.  And  the  need  for  it  will  not  be 
felt  by  English  readers,  who  have  had  provided  for  them  the 
admirable  manual  by  Treves  on  Intestinal  Ohstniction. 

For  clinical  purposes,  we  may  divide  the  forms  of  intestinal 
obstruction  into  Acute  and  Chronic  :  the  one,  where  the  symp- 
toms come  on  suddenly  in  a  patient  who  has  shown  no  previous 
symptoms  of  disease;  the  other,  where  the  onset  is  more  or  less 
slow,  or  where  there  have  been  previous  signs  of  intestinal 
disease.     Thus  classified,  the  varieties  are : 

Acute, 

I.    Strangulation  by  bands  or  through  apertures. 
II.   Volvulus. 

III.  Intussusception. 

Chronic. 

IV.  Stricture  from  disease  in  the  walls  of  the  gut,  cica- 

tricial or   neoplastic. 
V.    Obstruction   in   the   lumen :    neoplasms,    gall-stones, 

enteroliths,  faeces,  and  foreign  bodies  generally. 
VI.    Obstruction  from  compression  outside  by  tumours,  &c. 

I.  Strangulation  by  Bands  or  through  Apertures  bears 
a  close  resemblance  to  ordinary  hernia,  not  only  in  symptoms 
and  causation,  but  also  in  treatment.  The  bowel  is  snared  in 
an  unyielding  opening,  which  obstructs  its  lumen  and  strangu- 
lates its  vessels.     The  small  gut  is  nearly  always  implicated. 

Various  forms  of  bands  are  described. 

(i)  Isolated  Bands  of  organised  Inflammatovy  Material — "  peritoneal 
false  ligaments,"  as  they  are  called — are  frequently  the  cause  of 
strangulation.  Such  bands  vary  greatly  in  length,  density,  and 
thickness  :  sometimes  they  are  round  ;  often  they  are  flat.     Not 


STRANGULATION    BY  BANDS.  417 

infrequently  several  such  bands  exist,  and  cases  are  recorded 
where  strangulation  took  place  simultaneously  under  two  false 
ligaments.  The  attachments  of  these  bands  present  an  almost 
endless  variety.  Frequently  one  end  is  attached  to  the  mesen- 
ter}^  the  other  being  inserted  into  any  part  of  the  peritoneum. 
Strangulation  takes  place  either  by  the  bowel  slipping  under 
the  band,  in  which  case  it  must  be  comparatively  short ;  or  by 
the  bowel  being  caught  in  a  twist  or  loop  of  the  band,  when  it 
must  be  long.  Sometimes  obstruction  is  caused  by  the  band 
dragging  on  the  bowel,  and  so  causing  kinking.  The  modes  of 
constriction  are  so  bewilderingly  varied,  that  it  is  impossible  to 
classify  them. 

(2)  Bands  or  Cords  of  Omentum  constitute  another  mode  of  con- 
striction. The  omentum  becomes  adherent  to  some  spot  in  the 
peritoneum  ;  the  whole,  or  part  of  it,  is  rolled  up  or  twisted  into 
a  cord,  which  constricts  the  bowel,  just  as  peritoneal  false 
ligaments  do.  Omental  bands  are  usually  thick  and  vascular. 
They  are  found  attached  to  any  site  where  omentum  can  reach ; 
and  that  is,  practically,  anywhere.  But  the}^  most  frequently 
have  an  origin  in  some  way  connected  with  old  herniae.  Multiple 
cords  and  multiple  constrictions  are  more  common  with  omental 
than  with  peritoneal  bands.  The  greater  length  and  mobility 
of  omental  adhesions  render  strangulation  through  noose  or  knot 
a  more  likely  occurrence  than  with  the  peritoneal  bands. 

(3)  Strangulation  by  Meckel's  Diverticulum  is  of  the  nature  of  the 
preceding.  Constriction  may  take  place  either  when  the  diver- 
ticulum is  attached  to  the  umbilicus  or  when  it  has  become 
adherent  at  some  novel  situation.  In  the  former  case,  the  tube 
may  be  wholly  or  partially  obliterated.  The  diverticulum  acts 
as  a  peritoneal  or  omental  band  by  constricting  gut  which  passes 
below  it,  or  by  forming  loops  in  which  the  gut  is  snared.  I  have 
operated  on  a  case  where  strangulation  was  caused  by  several 
coils  of  bowel  passing  between  the  abdominal  wall  and  a  par- 
tially obliterated  Meckel's  diverticulum.  Mere  dragging  on  the 
diverticulum,  by  causing  kinking  or  setting  up  inflammation, 
may  induce  intestinal  obstruction.  False  diverticula  have  not 
been  found  associated  with  the  complaint. 

28 


418  LAPAROTOMY  FOR   OBSTRUCTION. 

(4)  Strangulation  by  Normal  Structures  which  have  become  ad- 
herent is  also  met  with.  Thus,  the  vermiform  appendix,  or  the 
Fallopian  tube,  or  the  appendices  epiploicse,  or  even  the  bowel 
and  the  mesentery  itself,  may  all  be  causes  of  intestinal  strangu- 
lation. I  have  operated  on  a  case  where  it  was  difficult  to  say 
whether  the  obstruction  was  caused  by  kinking  from  draggmg 
on  an  old  adhesion  to  the  parietes,  or  by  compression  of  a 
portion  of  bowel  which  passed  over  it. 

(5)  Strangulation  may  take  place  through  slits  or  holes  in  the 
mesentery,  or  the  omentum,  or  even  in  such  situations  as  the 
broad  ligament  of  the  uterus  and  the  suspensory  ligament  of  the 
liver.  Strangulation  by  the  gut  becoming  caught  in  the  foramen 
of  Winslow  has  been  described.  Mr.  Treves*  has  operated  on 
such  a  case,  but  found  it  impossible  to  effect  reduction.  About 
fifty  examples  of  retro-peritoneal  or  mesenteric  hernia,  from 
the  bowel  getting  entangled  in  the  fossa  duodeno-jejunalis,  have 
been  described. 

In  the  great  majority  of  cases  owning  the  above  causes,  the 
small  bowel  is  the  part  involved,  and  in  most  of  these  the  lower 
part  of  the  ileum.  The  probability  of  site  advances  almost  in 
geometrical  progression  from  duodenum  to  caecum.  The  length 
of  intestine  strangulated  ranges  from  a  mere  nipping  of  part  of 
the  calibre,  to  a  capture  of  several  feet.  The  average  length  is 
a  little  over  a  foot ;  but  the  limits  are  so  wide  apart,  that  any 
average  is  misleading. 

The  mechanism  of  obstruction  is  essentially  the  same  as 
in  external  hernia.  Simple  entanglement,  followed  by  con- 
gestion and  partial  or  complete  obstruction,  will  explain 
many  cases ;  others  are  completely  strangulated  from  the 
outset ;  a  few,  after  the  bowel  has  been  caught  and  held  for 
some  time,  undergo  strangulation  by  a  sudden  and  final  twist 
or  contortion.  Senn's  recent  experiments  show  that  in  circu- 
lar constriction  of  the  intestine  the  immediate  cause  of  gan- 
grene is  due  to  obstruction  of  the  venous  circulation,  and 
takes  place  at  a  point  most  remote  from  the  cause  of  the 
obstruction. 

*  Lancet,  Oct.  13,  1888. 


VOLVULUS.  419 

II.  Volvulus  is  the  name  given  to  occlusion  caused  by 
torsion  of  the  bowel,  or  rotation  round  its  axis  of  attachment. 
In  some  cases,  simple  twisting  is  the  cause ;  in  others,  two 
suitable  coils  become  mutually  intertwined.  Volvulus  is  found 
at  the  sigmoid  flexure,  in  the  caecum  and  ascending  colon,  and 
in  the  small  intestine. 

(i)  Volvulus  of  the  Sigmoid  Flexure  about  its  mesenteric  axis  is 
the  most  common  form;  two -thirds  of  all  cases  are  of  this 
nature.  The  Q-shape  of  this  part  of  the  gut,  the  length  and 
loose  attachment  of  its  mesentery,  and  its  tendency  to  become 
overloaded  and  displaced  by  collections  of  faeces,  explain  its 
liability  to  volvulus.  The  bowel  may  be  twisted  once  or  twice, 
or  even  three  times  around  its  axis.  In  another  class  of  cases 
the  sigmoid  loop,  acting  as  a  pedunculated  tumour,  becomes 
intertwined  with  a  loop  of  small  bowel,  and  induces  strangula- 
tion of  both. 

(2)  Volvulus  of  the  Cacum,  or  of  the  caecum  and  colon  adjoining, 
is  easily  understood.  Mere  acute  flexure  of  the  caecum  may 
block  its  passage ;  in  such  cases,  however,  there  is  usually  some 
congenital  malformation.  In  rotation  of  the  caecum  upon 
itself,  the  colon  is  liable  to  be  implicated,  more  especially  if 
there  is  a  long  meso-colon.  As  with  the  sigmoid  flexure,  so 
here  obstruction  may  be  caused  by  the  intertwining  of  small 
intestine.  Volvulus  of  the  ascending  colon  is  rare,  and  usually 
depends  on  anatomical  abnormality.  Volvulus  of  the  caecum 
may  be  subacute  or  chronic.  I  have  treated  with  a  medical 
colleague  a  case  where,  with  only  about  half  a  rotation,  there 
was  enormous  caecal  distension ;  the  distended  bowel  occupied 
half  the  abdominal  cavity. 

(3)  Volvulus  of  the  Small  Intestine  is  rare.  It  may  arise  from  the 
simple  twisting  of  one  coil,  or  from  the  intertwining  of  two 
loops.  An  abnormally  long  mesentery,  as  from  an  old  hernia,  is 
a  predisposing  cause.  The  simple  twist  is  usually  through  one 
complete  circle,  and  is  most  frequently  from  left  to  right.  Vol- 
vulus by  the  intertwining  of  two  loops  is  very  rare. 

III,  Intussusception    or    Invagination   of  the  intestine 

28  * 


420  LAPAROTOMY  FOR   OBSTRUCTION. 

means  the  prolapse  of  a  part  of  bowel  into  the  lumen  of  the 
part  adjoining.  It  is  the  most  frequent  single  cause  of  intestinal 
obstruction,  constituting  more  than  one-third  of  all  cases.  The 
pathological  anatomy  of  intussusception  is  well  understood,  and 
need  not  be  dwelt  upon.  One  portion  of  bowel  catches  another 
portion  just  above  it,  grasps  it  as  if  it  were  food,  and  pushes  it 
along,  invaginating  more  and  more  of  it.  The  portion  pushed 
inside,  consisting  of  an  entering  and  a  returning  layer  placed 
peritoneum  to  peritoneum,  is  known  as  the  intussusceptum. 
The  sheath  or  containing  bowel  is  known  as  the  intussuscipiens. 
The  neck  is  at  the  entrance  of  the  invagination,  where  the 
sheath  joins  the  returning  layer.  Rare  varieties  are  met  with 
where  double  or  triple  intussusceptions  take  place,  where  a 
second  intussusception  is  invaginated  in  a  first,  or  a  third  inside 
both.  A  retrograde  invagination,  where  a  descending  invagina- 
tion is  associated  with  an  ascending  one,  is  described. 

When  invagination  is  complete,  adhesions  form  between  the 
opposed  peritoneal  surfaces  of  the  entering  and  returning  layers, 
and  these  after  a  time  become  so  strong  as  to  render  reduction 
impossible.  Mere  invagination  need  not  cause  obstruction ;  it 
is  only  when  the  opening  in  the  intussusception  becomes  incurved 
by  the  dragging  of  the  mesentery,  or  the  walls  become  swollen 
from  congestion  or  inflammation,  that  obstruction  takes  place. 
The  invaginated  portion,  as  a  rule,  undergoes  inflammatory 
changes,  which  end  in  adhesion  of  the  intestinal  cylinders ;  or 
have  more  pronounced  results  in  rupture  of  vessels  from  intense 
congestion,  causing  discharge  of  blood  by  the  rectum ;  or  even 
terminate  in  gangrene.  Sloughing,  with  separation  of  the 
sphacelated  portion,  is  found  chiefly  in  cases  of  acute  intussus- 
ception, though  it  is  not  uncommon  in  chronic  cases.  This 
sloughing,  according  to  Senn,  is  caused  by  obstruction  to  the 
return  of  venous  blood  by  constriction  at  the  neck  of  the 
intussuscipiens. 

There  is  a  curious  connection  between  epithelioma  and 
intussusception.  Most  probably  the  epithelioma  was  the  origi- 
nator. The  indurated  mass  gets  caught  in  the  bowel,  is  passed 
on  as  the  apex  of  an  intussusception,  and  there  it  continues 


STRICTURE.  421 

growing.  It  is,  however,  quite  consistent  with  what  we  know 
of  the  origin  of  epithelioma  that  it  should  have  started  in  the 
ulcerating  areas  of  the  chronic  intussusception. 

Into  the  extremely  interesting  questions  of  the  origin  and 
cause  of  intussusception,  I  cannot  here  enter.  I  believe  that 
many  of  the  cases  of  acute  colic  produced  by  eating  indigestible 
substances  are  intussusceptions  which  right  themselves.  The 
frequency  of  intussusception  of  the  dying  is  much  greater  than 
is  generally  supposed ;  if  carefully  looked  for,  at  least  one  body 
out  of  four  will  show  it  on  the  post-mortem  table. 

Intussusception  may  take  place — (i)  in  the  small  bowel,  (2) 
in  the  colon  or  rectum,  or  (3)  in  the  ileo-csecal  region.  In  the 
small  bowel,  it  is  found  most  frequently  in  the  lower  jejunum ; 
and  next  in  frequency,  though  in  the  proportion  of  four  to  one, 
in  the  ileum.  The  narrow  calibre  of  the  small  bowel  prevents 
any  considerable  amount  of  invagination ;  rarely  is  more  than  a 
foot  engaged. 

Intussusception  of  the  large  bowel  may  occur  at  any  part 
of  its  course.  But  it  is  not  common,  and  when  it  does  occur 
it  is  small,  particularly  in  the  rectum. 

The  most  common  site  of  intussusception  is  in  the  ileo-caecal 
region.  Two  varieties  are  here  met  with — the  ileo-caecal  and 
the  ileo-colic.  In  the  former,  the  ileo-caecal  valve  forms  the 
apex  of  the  intussusception,  and  passes  up  the  colon,  followed 
by  the  caecum  and  the  ileum.  In  the  latter,  the  ileum,  passing 
through  the  ileo-caecal  valve,  is  invaginated  up  the  colon. 
A  rare  and  complicated  variety  is,  where  a  primary  invagina- 
tion of  the  end  of  the  ileum  is  either  passed  through  the 
valve  into  the  colon,  or  invaginated  into  the  colon  along  with 
the  caecum. 

IV.  Changes  in  the  Substance  of  the  Intestinal  Wall 
may,  by  narrowing  the  lumen,  be  a  cause  of  obstruction.  Such 
changes  may  be  of  the  nature  of  simple  cicatricial  stricture,  or 
of  new  growths. 

(i)  Simple  Sfyicture  is  produced  by  cicatricial  contraction 
of  organised   inflammatory  material  replacing  an  old  ulcer,  or 


422  LAPAROTOMY  FOR  OBSTRUCTION. 

loss  of  substance,  or  following  any  chronic  inflammation.  Ulcers 
may  originate  in  enteric  fever,  dysentery,  or  catarrh ;  peptic 
ulcer  in  the  duodenum  ;  syphilis  or  phthisis.  As  originating  in 
chronic  inflammation,  stricture  is  seen  in  its  most  typical  form 
in  bowel  that  had  been  engaged  in  an  old  hernia.  Any  injury 
to  the  bowel  may  result  in  cicatricial  stricture. 

(2)  Stricture  may  be  caused  by  the  development  of  new 
growths,  malignant  or  benign.  The  malignant  stricture  is  nearly 
always  of  the  nature  of  epithelioma  of  the  cylindrical  variety  ; 
scirrhus  and  encephaloid  are  almost  unknown.  Epithelioma 
typically  appears  as  a  hard  band  embedded  in  the  wall  of  the 
intestine,  and  constricting  its  lumen  as  if  by  a  tightly-drawn 
ligature.  The  constriction  is  not  always  annular  ;  sometimes  it 
is  in  broad  and  diffused  areas  over  a  considerable  portion  of  the 
intestinal  wall.  Thickening  of  the  peritoneal  and  muscular 
coats  is  always  present.  Epithelioma  of  the  intestine  is  practi- 
cally always  single  and  localised,  and  the  mesenteric  glands  are 
late  in  becoming  affected.  As  existing  in  the  rectum,  within  the 
reach  of  the  exploring  finger,  and  treated  by  a  special  operation 
— colotomy — the  disease  will  again  come  under  review. 

Sarcoma  and  lympho-sarcoma  are  rarely  found  as  causes  of 
obstruction. 

New  growths  of  benign  nature — such  as,  adenomata,  tumours 
of  pure  fibrous  tissue,  or  of  fibrous  and  muscular  tissue  com- 
bined ;  fatty  and  vascular  growths ;  and  growths  of  a  cystic 
nature*  have  all  been  known  to  cause  obstruction  :  but  they  are 
by  no  means  common. 

V.  Obstruction  by  a  Foreign  Body  blocking  the  lumen  of 
the  gut  is  sometimes  found.  In  this  class  must  be  reckoned  the 
accumulation  of  faeces.  Foreign  bodies  swallowed  and  becoming 
aggregated,  gall-stones,  and  intestinal  calculi  or  enteroliths,  are 
causes  of  intestinal  obstruction.  Some  polypi  or  pedunculated 
adenomata  cause  obstruction  by  their  bulk  in  the  cavity  of  the 
bowel. 

*  See  Janicke  and  Buchvvald,  Deutsche  med.  Woch.,  1887,  xl.     Also 
Abstract  in  Lond  Med.  Rec,  Nov.  15th,  1887. 


DIAGNOSIS.  423 

In  such  cases  obstructed  circulation  and  strangulation  of  the 
bowel  do  not  occur,  and  the  symptoms  in  consequence  are  not, 
at  first,  very  urgent. 

VI.  Compression  of  the  Gut  by  Tumours  outside  of  it 
forms  a  separate  class.  Obstruction  may  be  produced  in  the 
most  varied  ways.  I  have  seen  a  case  where  alarming  symptoms 
of  intestinal  obstruction  were  produced  by  retroversion  of  the 
gravid  uterus,  pressing  probably  on  entangled  loops  of  small 
bowel.  All  sorts  of  growths — solid  or  cystic,  or  even  abscesses 
in  the  peritoneal  cavit}^ — may  press  on  the  bowel  and  block  its 
passage.  Growths  of  the  liver  or  pancreas  may  cause  obstruc- 
tion in  the  duodenum  ;  tumours  of  the  ovary,  uterus,  or  pelvic 
bones,  may  compress  the  rectum  ;  and  the  small  bowel  may  be 
compressed  by  tumours  in  any  part  of  the  peritoneal  cavity. 
Naturally,  the  less  movable  parts  of  intestine  are  most  likely  to 
suffer. 

Usually  such  causes  provide  examples  of  chronic  obstruction. 
The  sudden  displacement  of  a  tumour  may,  however,  produce 
sudden  obstruction,  with  acute  symptoms. 


diagnosis  of  intestinal  obstruction. 

In  cases  of  acute  obstruction,  the  onset  is  sudden  ;  the 
symptoms  from  the  beginning  are  urgent ;  and  the  result,  after 
a  rapid  course,  is  almost  uniformly  fatal.  Spontaneous  recovery 
after  volvulus  is  unknown ;  a  very  small  proportion  of  cases  of 
intussusception  get  well ;  and  genuine  examples  of  recovery 
after  strangulation  by  bands  or  through  apertures  must  be  less 
common  than  in  ordinary  hernia,  where  the  chance  of  recovery 
is  practically  considered  as  nil.  In  the  case  of  the  last,  recovery 
takes  place  from  gangrene  of  the  gut,  with  the  formation  of  false 
anus  ;  in  internal  obstruction,  gangrene  is  certain  death.  There 
is  a  variety  of  intussusception  which  is  chronic,  and  is  not 
reckoned  among  examples  of  acute  strangulation. 

The  symptoms  are  those  of  strangulated  hernia,  aggravated. 
Severe   abdominal   pain,  collapse,  vomiting,   constipation,  and 


424  LAPAROTOMY  FOR   OBSTRUCTION. 

abdomina]  distension  are  the  leading  symptoms.  The  pain  is 
always  severe  and  often  agonising.  It  is  frequently  intermittent, 
and  liable  to  exacerbations — possibly,  as  Treves  suggests,  on 
account  of  the  intermitting  nature  of  the  construction.  The 
character  of  the  pain  varies  :  sometimes  it  is  of  the  nature  of 
severe  colic,  pure  and  simple ;  at  other  times,  a  sensation  is 
felt  as  if  a  band  were  drawn  tightly  round  the  abdomen. 
The  site  of  the  pain  is  not  a  trustworthy  guide  to  the  seat  of 
obstruction. 

Collapse,  always  marked,  often  alarming,  attends  every  case 
of  acute  intestinal  obstruction.  We  may  expect  to  find  the 
collapse  most  severe  in  cases  where  the  onset  is  very  sudden, 
and  the  patient  is  young  and  vigorous.  Profound  collapse 
suggests  complete  strangulation  ;  but  the  degree  of  it  is  no  guide 
to  the  amount  of  bowel  involved. 

Vomiting  is  always  an  early  and  well-marked  symptom. 
The  irritated  bowels  soon  become  filled  to  distension  with 
secretions,  fluid  and  gaseous ;  and,  under  increased  abdominal 
pressure  and  the  constant  contractions  of  the  intestinal  muscle, 
these  secretions  escape  by  the  only  possible  exit — the  stomach. 
Anti-peristalsis,  or  Dr.  Brinton's  ^yell-known  explanation  of  the 
process  by  the  production  of  an  axial  and  a  peripheral  current, 
may  account  for  this  vomiting.  But  such  explanations  are  no 
more  necessary  to  explain  the  regurgitation  of  the  intestinal 
contents  in  the  living  than  in  the  dead.  Mere  gaseous  disten- 
sion and  increased  abdominal  pressure  force  the  contents  out  of 
the  mouth  after  death  ;  and  these  passive  causes,  in  addition  to 
the  very  active  one  of  intestinal  contractions,  may  do  the  same 
during  life. 

The  vomiting  may  or  may  not  be  attended  with  retching. 
Sometimes  the  fluids  are  ejected  in  great  gushes  without  much 
straining  effort.  The  vomit  at  first  consists  of  the  natural 
contents  of  the  bowel ;  then,  of  bile-stained  fluids  ;  then,  of  dark 
grumous  material — "  coffee -ground  ";  and  finally,  of  faecal 
matter,  more  or  less  diluted.  That  faecal  matter  may  be 
vomited,  even  if  the  constriction  is  well  above  the  large  bowel, 
there  is  no  longer  any  dispute ;  but  we  should  not  expect  faecal 


DIAGNOSIS.  425 

vomiting  if  the  constriction  is  not  below  the  jejunum.  At  first 
the  vomiting  may  be  of  the  nature  of  a  reflex  nerve  symptom ; 
later  on,  it  is  mainly  a  mechanical  discharge  of  accumulated 
secretion,  and  the  existence  and  continuance  of  such  vomiting 
affords  relief  to  the  patient. 

Constipation,  absolute  and  insuperable,  is  an  important  sign. 
Occasionally  at  an  early  stage  of  the  complaint,  faeces  are 
passed  from  the  bowel  below  the  seat  of  constriction  ;  but  when 
the  disease  is  well  established,  neither  faeces  nor  flatus  pass. 
Discharge  of  blood  by  the  anus  is  found  in  a  considerable 
number  of  cases  of  intussusception. 

Abdominal  distension,  from  the  accumulation  of  gas  and 
fluid,  is  an  early  and  prominent  symptom.  It  increases  with 
the  duration  of  the  illness ;  and  in  marked  examples  the 
parietes  may  be  tense,  like  a  drum,  and  visibly  white  and 
glistening  from  being  stretched.  In  such  cases  mechanical 
obstruction  to  respiration  is  present.  Tympanitic  reso- 
nance all  over  the  abdomen,  except  perhaps  in  the  flanks, 
is  marked. 

It  need  scarcely  be  added  that,  in  making  the  diagnosis,  all 
the  usual  sites  of  external  hernia  must  be  explored,  and  the 
rectum  must  be  digitally  examined. 

The  Diagnosis  from  other  Diseases  is  not  often  difficult.  A 
localised  paralysis  of  the  gut,  from  inflammation  of  its  walls  or 
from  nerve  disturbance,  may  produce  sj-mptoms  very  similar  to 
those  of  intestinal  obstruction.  A  bruise  or  crush  of  the  bowel, 
inflammation  after  reduction  of  a  strangulated  hernia,  are  prac- 
ticall}^  varieties  of  obstruction.  Decending  testicle  becoming 
incarcerated  or  inflamed  is  well  known  to  cause  symptoms  like 
those  of  obstruction.  I  have  been  called  to  treat  a  man  aged 
76  for  urgent  symptoms  of  obstruction,  which  were  found  to  be 
produced  by  inflammation  in  a  testicle,  which  lay  undescended 
in  the  inguinal  canal,  and  I  have  seen  two  similar  cases  in 
hospital  practice. 

Acute  peritonitis  may  be  mistaken  for  intestinal  obstruction; 
in  fact,  the  mistake  has  been  made  on  not  a  few  occasions.  If 
peritonitis  is  caused  by  perforation,  the  symptoms  may  be  most 


426  LAPAROTOMY   FOR   OBSTRUCTION. 

misleading.  A  few  hours  will,  however,  make  the  diagnosis 
clear.  The  temperature  is  no  guide ;  the  worst  cases  of  perito- 
nitis may  have  a  normal,  or  even  subnormal,  temperature.  The 
nature  of  the  onset,  the  character  of  the  vomiting,  the  quality  of 
the  pain,  and,  most  important  of  all,  the  palpation  of  the 
abdomen,  will  also  guide  us.  Lead  colic,  accompanied  as  it 
often  is  with  obstinate  constipation,  and  renal  or  hepatic  colic, 
where  pain,  collapse,  and  vomiting  may  be  present,  might  also 
be  mistaken  for  intestinal  obstruction. 

The  Diagnosis  of  the  Variety  of  Obstruction  may  be  attended 
with  considerable  difficulty.  It  is  nearly  always  possible  to 
say  whether  the  case  is  one  of  acute  or  of  chronic  obstruction  ; 
the  difficulties  appear  in  the  diagnosis  of  the  individual  variety. 

A  chronic  case,  in  which  the  primary  symptoms  have  been 
obscure,  may  suddenly  become  acute.  The  terminal  symptoms 
of  all  cases  of  obstruction  are  very  similar. 

The  Symptoms  of  Acute  Obstruction  are  as  follows  :  The  patient, 
in  ordinary  health,  is  suddenly  seized  with  severe  abdominal 
pain  of  a  griping  character,  with  exacerbations.  He  is  at 
once  prostrated,  suffers  from  shock,  and  his  face  indicates  the 
patient's  consciousness  that  he  is  seriously  ill.  Vomiting  very 
soon  follows  the  first  attack  of  pain,  and  continues  at  irregular 
but  short  intervals.  There  is  absolute  constipation,  and 
abdominal  distension  which  goes  on  increasing  with  the  duration 
of  the  malady. 

It  must  be  noted  that  acute  symptoms  occasionally  supervene 
on  chronic  causes ;  and  the  reverse,  to  a  more  limited  extent, 
holds  true. 

The  diagnosis  of  the  Variety  of  Acute  Obstruction  may  often  be 
successful. 

Strangulation  by  Bands. — The  patient  is  probably  a  young 
male  adult,  who  will  usually  have  a  previous  history  of  perito- 
nitis. In  a  few  cases  a  previous  attack  of  obstruction,  partial 
and  mild,  will  be  recorded.  The  disease  will  have  attacked  him 
suddenly,  and  without  warning,  in  the  midst  of  his  ordinary 
pursuits.  The  pain,  which  from  the  beginning  is  severe,  is 
continuous,  with  exacerbations,  and    is  usually  located  in  the 


DIAGNOSIS.  427 

region  of  the  umbilicus.  There  is  no  tenderness  on  pressure. 
Vomiting  soon  comes  on,  and  is  frequent  and  copious.  In  more 
than  half  the  cases,  it  becomes  stercoraceous  about  the  fourth 
or  fifth  day.  From  the  first  constipation  is  complete.  No  blood 
is  discharged.  Extreme  prostration,  or  even  profound  collapse, 
may  be  present  from  the  beginning ;  usually  it  is  most  marked 
at  the  onset,  and  becomes  less  marked  afterwards.  Abdominal 
distension  is  not  at  first  a  marked  symptom.  No  tumour  is  felt 
on  palpation. 

Such  cases  die  about  the  fifth  or  sixth  day. 

Volvulus  of  the  Small  Intestines  presents  symptoms  very  similar 
to  the  above.  Volvulus  of  the  Colon,  nearly  always  at  the  sigmoid 
flexure,  presents  more  distinctive  symptoms.  It  is  usually  found 
in  males,  after  the  age  of  forty,  who  have  suffered  for  some  time 
from  constipation.  Pain  comes  on  at  once,  but  it  is  not  so  severe 
as  in  strangulation  through  bands,  and  it  frequently  intermits. 
Occasionally  the  pain  is  referred  to  the  hj^pogastrium  or  the 
back.  Tenderness  on  pressure  comes  on  as  the  disease  con- 
tinues. Vomiting  comes  on  late,  or  not  at  all,  and  is  never  very 
urgent.  In  only  fifteen  per  cent,  of  the  cases  does  it  become 
faeculent.  Prostration  is  never  extreme.  Constipation  exists 
from  the  first. 

A  distinctive  symptom  is  a  rapid  and  excessive  accumulation 
of  gas,  which  soon  causes  great  distension  of  the  abdomen. 

The  average  duration  of  life  is  about  six  days. 

Acute  Intussusception  usually  appears  in  children.  Pain  is  a 
prominent  symptom  ;  it  comes  on  in  waves,  reaching  a  point  of 
great  intensity,  and  then  subsiding.  Vomiting  is  a  very  variable 
symptom  :  sometimes  it  is  present  from  the  onset,  and  is  copious 
and  frequent ;  at  other  times  it  comes  on  late,  and  is  never 
severe ;  a  few  have  no  vomiting  at  all.  The  most  characteristic 
sign  is  the  discharge  of  blood  by  the  rectum,  frequently  attended 
with  diarrhoea  and  tenesmus.  A  definite  tumour  is  frequently 
palpated  through  the  parietes  ;  and,  in  intussusceptions  affecting 
the  large  bowel,  the  apex  of  the  invaginated  bowel  may  be  felt 
through  the  rectum.  Abdominal  distension  is  usually  absent ; 
occasionally  the  abdomen  is  retracted. 


428  LAPAROTOMY  FOR   OBSTRUCTION. 

These  cases  may  be  fatal  within  twenty-four  hours  ;  or  they 
may  last  for  several  days ;  or  they  may  become  chronic,  lasting 
for  weeks. 

The  Symptoms  of  Chronic  Obstruction  need  not  be  detailed. 
They  are  simply  those  of  acute  obstruction  in  a  milder  form, 
and  prolonged  over  a  longer  period. 

Stricture  of  the  Small  Bowel  may  be  taken  as  representative  of 
a  large  class  of  cases  whose  symptoms  are  broadly  as  follows. 
In  such  there  is  usually  some  previous  history  of  intestinal 
trouble,  followed  at  a  considerable  interval  by  attacks  of 
obstruction,  gradually  increasing  in  gravity  till  the  final  attack 
which  jeopardises  the  life  of  the  patient.  Pain  comes  on  in 
paroxysms,  and  completely  intermits  :  not  infrequently  it 
appears  after  eating.  Vomiting  is  not  an  urgent  symptom  ; 
it  is  late  in  coming  on,  is  neither  frequent  nor  copious,  and 
rarely  is  faeculent.  Constipation,  not  absolute,  or  alternating 
with  diarrhoea,  will  be  present.  Before  the  final  attack,  the 
patient  will  have  lost  flesh  and  spirits.  Abdominal  distension 
is  replaced  by  attacks  of  flatulence,  more  or  less  distressing; 
but  never,  except  at  the  end,  causing  dyspnoea. 

Such  cases  may  last  for  a  month  or  more.  In  most  cases, 
however,  more  or  less  acute  symptoms  supervene  on  the  chronic, 
with  corresponding  curtailment  of  the  duration  of  life. 

It  is  rarely  possible,  unless  a  distinct  tumour  is  felt,  to 
diagnose  simple  from  malignant  stricture.  The  history  may 
be  of  some  assistance,  however.  Anything  which  causes 
gradual  obliteration  of  the  bowel,  tumours  outside  or  inside, 
contracting  adhesions,  and  all  such  conditions,  may  produce 
identical  S3'mptoms. 

Stricture  of  the  Large  Bowel  has  most  features  in  common  with 
stricture  of  the  small  bowel.  There  are  the  same  irregular 
beginnings,  and  the  same  exacerbations,  with  occasional  inter- 
missions. Vomiting  is  less  frequent  in  stricture  of  the  large 
bowel.  Distension  is,  however,  always  a  marked,  and  often  a 
very  troublesome,  accompaniment  ;  and  tenesmus,  with  the 
discharge  of  blood,  mucus,  or  pus,  is  often  found. 


INDICATIONS  FOR   OPERATION.  429 

As  cancer  of  the  rectum,  malignant  stricture  is  perhaps 
the  best  known  of  all  causes  of  intestinal  obstruction. 

Fcecal  Accumulations  have  some  special  features  of  their  own. 
They  occur  chiefly  in  women  who  have  passed  the  prime  of  life, 
and,  more  particularly,  in  lunatics.  The  symptoms  are  simply 
those  of  constipation,  becoming  more  and  more  intractable. 
There  is  usually  a  palpable,  or  even  visible,  tumour  having  the 
characters  of  faeces.  The  abdomen  becomes  generally  dis- 
tended with  gas  or  faeces,  or  both.  Pain  of  a  paroxysmal 
nature  supervenes.  Vomiting  is  late  in  appearing,  and  is  long 
in  becoming  faeculent.  There  may  be  a  history  of  previous 
attacks. 

This  is  about  as  far  in  differential  diagnosis  as  our  present 
knowledge  will  carry  us.  Individual  variations  of  symptoms 
must  be  allowed  to  each  case  on  a  liberal  scale.  The  differences 
between  a  cumulative  and  an  instantaneous  cause, — between 
strangulation  and  mere  obstruction  ;  between  obstruction  in  the 
small  bowel  and  obstruction  in  the  large  bowel, — theoretically 
marked  enough,  are  found  in  practice  to  be  very  difficult  of 
detection.  But,  by  a  careful  summation  of  the  concrete  symp- 
toms in  each  case,  it  will  nearly  always  be  possible  to  form  a 
tolerably  correct  opinion  as  to  the  exact  nature  of  the  obstruc- 
tion, and  formulate,  either  at  once  or  after  waiting  a  few  hours, 
a  consistent  and  definite  plan  of  treatment. 


INDICATIONS    FOR    OPERATION. 

The  indications  to  operate  in  any  given  case  depend,  in  the 
first  place,  upon  the  chance  which  the  patient  has  of  getting 
well  without  operation  ;  and,  in  the  second  place,  upon  the 
degree  of  probability  with  which  success  will  follow  the 
operation. 

To  cases  of  acute  obstruction  there  is  practically  but  one 
termination — death.  No  case  of  volvulus,  whether  of  large  or 
small  intestine,  has  as  yet  been  known  to  recover  under  treat- 
ment purely  medicinal.  Spontaneous  recovery,  in  the  numerous 
class  of  cases  of  strangulation  by  bands,  is  not  to  be  looked  for. 


430  LAPAROTOMY  FOR   OBSTRUCTION. 

In  the  case  of  intussusception,  where  we  have  been  accustomed 
to  look  for  favourable  results  without  operation,  it  seems  to 
me  that  Treves  has  made  out  a  clear  case  against  expectant 
treatment.  Looked  at  from  the  side  of  causation,  or  actual 
pathological  condition,  there  is  practically  no  expectation  of 
recovery.  Certainly  ninety-five  per  cent,  of  all  such  cases 
die. 

Here,  then,  the  indication  is  clear  enough — as  clear  as  the 
indication  to  tie  a  bleeding  carotid — operation.  In  the  sense 
of  avoiding  the  risk  of  death,  the  indication  is  more  definite 
than  in  external  hernia  ;  for  in  hernia  there  is  a  chance  of 
recovery  by  gangrene.  In  the  sense  of  promoting  the  chances 
of  recovery,  the  indication  is  not  so  strong ;  for  more  cases  of 
external  herniotomy  must  always  recover,  than  of  internal. 
The  risks  are  increased  in  the  same  way  by  waiting,  and  by 
handling  or  purgation — which  are  almost  the  same  in  evil  effect. 
There  is  but  one  treatment — release  of  the  strangulated  bowel 
from  the  strangulating  band. 

From  the  pathological  standpoint,  it  is  easy  enough  to  be 
definite ;  but  not  so  from  the  diagnostic.  We  are  too  seldom 
certain  of  the  diagnosis,  to  be  always  dogmatic  as  to  the 
treatment.  But  if  we  are  doubtful  whether  we  can  do  good 
by  operating,  we  may  be  certain  there  are  many  ways  of  doing 
harm  by  administering  drugs.  There  never  yet  was  a  case  of 
true  intestinal  strangulation  in  which  purgatives  did  not  do 
harm  ;  and  not  one  out  of  ten  escapes  purgation.  Emetics 
may  do  good ;  even  bleeding  may  not  do  harm ;  but  certainly 
purgation  is  baneful.  I  say  nothing  about  manipulation  of  the 
abdomen  under  an  ansesthetic.  The  cases  of  success  recorded 
certainly  do  not  read  hke  cases  of  acute  obstruction.  But 
manipulation  early  in  the  case  ought  to  be  less  harmful  than 
purgation. 

At  once,  or  within  a  few  hours,  we  ought  to  make  a  definite 
diagnosis.  If  we  are  convinced  that  it  is  acute  obstruction, 
then  operation  should  be  performed  at  once;  if  we  are  con- 
vinced that  it  is  not,  another  treatment  equally  definite  ought 
to  be  pursued.     From  the  beginning  a  definite  plan  of  treatment 


INDICATIONS  FOR   OPERATION.  431 

ought  to  be  laid  down,  and  this  plan  ought  to  be  adhered  to. 
Let  it  be  either  drugs  or  operation,  and  never  that  fatal  com- 
promise— operation  when  drugs  fail. 

The  indications  for  operation  in  chronic  and  sub-acute  cases 
are  by  no  means  fixed  and  definite.  Generally  speaking,  when, 
in  a  chronic  case,  we  find  that  in  spite  of  careful  dieting  and 
treatment  the  attacks  of  obstruction  become  more  numerous 
and  more  severe,  and  finally  if  one  attack  supervenes  which  is 
positively  insuperable  and  is  rapidly  kihing  the  patient,  then 
operation  is  indicated.  But,  with  this,  some  conception  must  be 
formed  as  to  the  nature  of  the  operation,  and  the  probable 
ultimate  effects  of  it.  Thus,  in  the  case  of  peritoneal  cancer 
obstructing  the  gut,  uncertainty  as  to  the  amount  of  bowel 
involved,  and  the  certainty  of  early  death  in  spite  of  operation, 
would  make  operation  scarcely  justifiable.  Cases  of  fsecal 
accumulation  sometimes  recover  after  the  patient  is  apparently 
in  extremis,  with  obstruction  lasting,  perhaps,  for  weeks  ;  and  in 
such  operation  is  rarely  indicated.  In  chronic  intussusception, 
the  question  of  operation  is  very  difficult  to  settle.  It  is  true 
that  cases  may  have  gone  on  for  weeks  without  the  formation 
of  strong  adhesions,  rendering  reduction  impossible  ;  but  this 
chance  is  not  to  be  reckoned  upon.  If  the  invagination  cannot 
be  reduced,  and  the  bowel  involved  cannot  be  removed,  we  have 
still  the  unsatisfactory  resources  of  making  an  artificial  anus 
above  the  intussusception,  or  of  forming  anastomosis  with 
another  piece  of  bowel  below  the  intussusception. 

In  many  cases  of  stricture  the  question  of  resection  of  the 
bowel  will  arise  :  this  will  be  considered  later.  In  the  case  of 
foreign  bodies  in  the  bowel,  treatment  must  be  guided  by  the 
urgency  of  symptoms  pointing  to  obstruction,  or  to  ulceration 
and  inflammation,  and  the  proved  inefficacy  of  other  means  of 
treatment. 

Some  discussion  has  taken  place  as  to  whether  it  is  advisable 
to  perform  laparotomy  for  intestinal  obstruction  if  peritonitis  is 
present.  Such  a  discussion  is  of  an  arm-chair  nature — a  reason- 
ing away  from  the  facts.  Peritonitis  is  present  in  every  case  of 
true  intestinal  obstruction  :  it  may  be  local  or  wide-spread,  and 


432  LAPAROTOMY  FOR   OBSTRUCTION.- 

it  may  be  serous,  plastic,  or  purulent.  It  is  an  essential  con- 
comitant of  the  disease.  In  a  marked  case  of  intestinal  obstruc- 
tion, I  doubt  if  the  separate  diagnosis  of  peritonitis  is  ever 
possible.  In  any  case  its  presence  can  be  no  contra-indication 
to  operation.  On  the  contrary,  if  other  circumstances  do  not 
forbid  it,  I  would  regard  peritonitis  as  a  positive  indication. 
It  would  be  just  as  valid  to  argue  against  the  performance 
of  herniotomy  because  there  was  fluid  in  the  hernial  sac,  as 
against  laparotomy  for  obstruction  because  there  was  fluid  in 
the  abdomen. 

Mortality  and  Appreciation. — The  death-rate  of  laparotomy 
for  intestinal  obstruction  is  high,  probably  more  than  70  per 
cent.  Even  thus  the  operation  would  still  be  justifiable ;  for 
nearly  every  case  which  recovers  may  be  reckoned  as  saved 
from  death,  and  the  deaths  are  only  hastenings  of  the  natural 
termination.  There  can  be  no  doubt  that  delay  is  the  chief 
cause  of  mortality.  We  know  how  successful  early  herniotomy 
is  :  surely,  in  the  face  of  recent  exploits  in  abdominal  surgery, 
early  laparotomy  for  intestinal  strangulation  ought  to  be  only 
a  little  less  successful.  Before  abdominal  distension  has  come 
on,  before  the  bowel  has  become  inflamed,  and  before  the 
patient's  strength  is  exhausted,  I  have  no  hesitation  in  affirming 
that,  in  competent  hands,  laparotomy  for  intestinal  obstruction 
would  not  have  a  mortality  above  fifteen  per  cent. 


THE    OPERATION. 

The  details  of  the  operation  include  what  is  common  to 
all  cases  of  obstruction,  and  what  is  special  to  each  variety. 
Some  of  the  special  proceedings  are  comparatively  trivial ; 
these  will  be  described  in  the  general  account :  others  are  of 
great  moment,  and  these  will  receive  separate  consideration. 

* 

These  patients  are  rarely  promising  subjects  for  anaesthesia. 
The  surgeon  is  usually  called  in  late,  when  the  patient's  heart  is 
very  weak,  and  his  stomach  and  intestines  are  full  of  fluid. 


THE  INCISION  433 

Vomiting,  liable  to  occur  during  the  anaesthetic,  is  full  of 
danger :  I  have  lost  one  patient  on  the  operating  table  from 
this  cause.  It  is  often  a  question  whether  the  stomach 
should  not  be  first  emptied  by  the  stomach-pump.  The  mere 
administration  of  an  anaesthetic  is  often  followed  by  alarming 
symptoms:  in  a  few  minutes,  though  the  operation  may  not  be 
severe  or  prolonged,  the  condition  of  the  patient  maybe  changed 
from  one  not  very  serious  to  one  positively  alarming.  This  fact 
has  so  strongly  impressed  me  that,  in  a  bad  case,  with  distended 
abdomen,  I  should  always  operate  without  general  anaesthesia ; 
make  the  incision,  a  very  short  one,  after  a  local  injection  of 
cocaine ;  be  content  with  a  short  exploration,  and,  if  the  cause 
were  not  found,  make  an  artificial  anus.  The  operation  may 
subsequently  be  completed  when  the  patient  is  out  of  danger. 
Enterotom)''  with  local  anaesthesia  is  a  very  simple  affair ; 
general  anaesthesia  with  an  explorator}^  laparotomy  is  a  very 
serious  matter  in  an  exhausted  patient  whose  hollow  viscera 
are  distended  with  fluid  and  gas. 

In  this  operation  we  have  specially  to  bear  in  mind  that  the 
prime  object  in  surgery  is,  not  merely  to  perform  a  scientific  and 
technically  complete  operation,  but  to  save  our  patient's  life. 
An  operation  for  intestinal  obstruction  is  certainly  not  completed 
till  the  cause  has  been  removed;  but  if  the  cause  can  be  removed 
only  after  a  prolonged  and  difficult  operation  at  the  expense  of 
the  life  of  the  patient,  then  I  maintain  it  is  better  to  temporise, 
save  the  patient's  life  by  enterotomy,  and  remove  the  constric- 
tion afterwards  when  the  patient  can  bear  it.  In  every  very  bad 
case  I  should  begin  by  putting  the  patient  out  of  immediate 
danger,  by  the  performance  of  enterotomy  without  general 
anaesthesia :  as  soon  as  he  can  bear  it  the  cause  of  strangu- 
lation may  be  sought  for,  and  the  operation  completed. 

The  Incision. — As  we  are  rarely  certain  of  the  site  of  obstruc- 
tion, we  must  adopt  a  form  of  incision  which  will  give  the 
greatest  range  and  freedom  for  exploration  and  operation.  This 
is  a  rnedian  incision,  about  midway  between  umbilicus  and  pubes 
if  the  abdomen  is  much  distended,  and  nearer  to  the  umbilicus 

29 


434  LAPAROTOMY  FOR   OBSTRUCTION. 

if  there  is  little  distension.  This  incision  is  adopted  merely  for 
its  convenience  in  exploring ;  there  is  no  strong  anatomical 
reason  against  adopting  any  other  site. 

The  incision  is  made  long  enough  to  admit  two  fingers. 
When  the  sub-peritoneal  fat  is  reached  it  bulges  into  the 
wound,  being  pushed  outwards  by  the  distended  bowels.  Tait's 
plan  of  opening  the  peritoneum,  by  pulling  it  outwards  between 
pairs  of  catch-forceps  and  dividing  the  raised  fold  between 
them,  is  the  best.  If  the  membrane  is  thin,  I  prefer  to  pinch 
it  up  between  the  finger  and  thumb,  roll  it  about  to  see  that  no 
bowel  is  included,  and  make  a  small  opening  at  the  top  of  the  fold 
with  the  scalpel.  The  opening  is  enlarged  by  scissors,  upwards 
and  downwards,  to  the  extent  of  the  external  wound — that  is, 
to  about  two  inches.  Bleeding  will  have  been  checked  in  the 
ordinary  way.  Jf  afterwards  found  necessary,  the  incision  may 
be  prolonged. 

Finding  and  Relieving  the  Obstruction. — The  plan  usually  recom- 
mended is  as  follows.  The  hand,  inserted  through  the  wound 
(for  this  purpose  the  incision  must  be  longer  than  that  recom- 
mended), is  first  carried  to  the  caecum.  If  it  is  found  much 
distended,  we  may  expect  to  find  the  cause  lower  down  some- 
where in  the  colon.  The  hand  follows  the  course  of  the  ascend- 
ing, transverse,  and  descending  colon  to  the  sigmoid  flexure, 
seeking  the  cause  of  obstruction  on  the  way.  If  it  is  not  in  the 
colon,  we  seek  for  it  in  the  small  bowel ;  and  for  tliis  purpose, 
we  are  told  to  find  and  follow  up  the  collapsed  bowel  below  the 
the  obstruction.  Lastl}^,  the  region  of  the  umbilicus  and  the 
promontory  of  the  sacrum,  as  being  likely  spots,  are  explored. 

Now,  these  are  excellent  directions,  from  the  pathologist's 
point  of  view  ;  and  they  would  be  easily  enough  carried  out  if 
the  bowels  were  not  distended,  and  the  abdominal  walls  not 
hard  and  tense.  To  explore  the  whole  length  of  the  colon 
through  tense  parietes  and  over  dilated  bowels  would  require 
that  the  arm  be  inserted  half  wa}'  up  to  the  elbow — particularly 
if,  as  is  often  the  case,  the  transverse  colon  is  pushed  upwards 
under  the  diaphragm.     And  to  follow  up  individual  coils  of  the 


FINDING    THE  OBSTRUCTION.  435 

small  bowel  with  the  hand  is  no  more  easy :  if  it  is  possible  at 
all,  it  is  tedious  and  difficult  in  the  extreme.  The  finding  of 
collapsed  bowel  would  be  of  assistance  :  but,  as  often  as  not, 
there  is  no  part  of  the  bowel  collapsed  ;  it  is  only  less  distended 
than  another  part.  The  passing  of  the  bowel  along  inch  by 
inch  will  certainly  expose  the  constriction,  but  it  will  probably 
kill  the  patient. 

I  believe  that  the  best  means  of  reaching  the  seat  of  con- 
striction will  be  by  inspection  of  the  bowel  presenting  at  the 
wound.  There  is  a  high  probability,  wherever  the  cause  lie, 
that  the  most  dilated  coils  will  rise  nearest  to  the  surface  ;  and, 
the  greater  amount  of  bowel  being  within  three  inches  of  the 
umbihcus,  there  is  a  further  probability  that  the  most  dilated 
coils  wnll  be  within  sight.  Very  gently  they  may  be  moved  first 
on  one  side,  then  on  the  other,  as  well  as  upwards  and  down- 
wards. The  most  dilated  portion,  which  will  be  also  the  most 
congested  or  not  far  off  it,  is  fixed  upon  and  followed  in  the 
direction  of  increasing  distension  and  congestion,  wherever  that 
may  lead.  It  will  certainly  lead  to  the  stricture.  The  whole 
manipulation  may  be  carried  out  with  two  fingers.  If,  now  that 
the  obstruction  and  the  nature  of  it  are  discovered,  it  seems 
necessary  to  prolong  the  incision  to  relieve  it,  this  can  be  done 
in  the  direction  which  is  most  convenient. 

Should  this  method  not  succeed  (it  has  failed  only  once  in 
twelve  cases  on  which  I  have  operated),  I  should  then  recommend 
the  insertion  of  the  hand  to  explore.  Should  this  also  fail,  I 
should  recommend  that  the  most  distended  portion  of  bowel  be 
permitted  to  extrude  under  a  large  flat  sponge,  wrung  out  of 
warm  antiseptic  lotion.  One  end  of  the  loop  will  extrude  less 
readily  than  the  other,  and  one  end  will  appear  to  become 
increasingly  congested  ;  these  characters  are  sure  guides  to  the 
seat  of  obstruction.  When  the  bowel  begins  to  show  that  it  is 
fixed  inside  the  abdomen,  or  when  the  evidences  of  congestion 
are  striking,  the  finger  inserted  along  this  portion  of  bowel  will 
detect  the  origin  of  the  mischief. 

This  protrusion  of  bowels  has  a  purpose  other  than  the 
providing  of  more  space  for  discovering  and  treating  the  cause 

29  * 


436  LAPAROTOMY  FOR   OBSTRUCTION. 

of  obstruction.  It  will  be  called  for  only  in  cases  of  great 
intestinal  distension ;  and  excessive  distension  I  believe  to  be  a 
condition  which  requires  relief  almost  as  urgently  as  actual 
strangulation.  This  distension  can  be  relieved  only  by  puncture 
o-r  incision  when  the  bowel  is  extruded. 

The  plan  of  permitting  bowels  to  protrude  has  been  very 
generally  and  very  heartily  condemned.  The  condemnation, 
however,  has  been  in  the  spirit  of  the  peritoneal  surgery  of  the 
last  generation,  rather  than  of  the  present.  In  the  face  of  the 
actual  practical  work  now  successfully  carried  out,  it  is  idle  to 
argue  that  extrusion  of  the  bowels,  properly  managed,  is  a 
source  of  serious  danger.  Less  damage  is  likely  to  be  inflicted 
on  bowels  by  a  soft  sponge  or  sponge-cloth  lightly  resting  on 
them,  than  by  a  rough  hand  pushing  them  about  under  great 
pressure  inside  the  abdomen.  Since  writing  the  above  for  the 
previous  editions,  I  am  glad  to  be  able  to  quote  a  good  many 
successful  practical  experiences  in  favour  of  my  view,  at  the 
hands  of  other  surgeons.  The  chief  objection  to  protrusion  of 
bowel  is  the  supposed  difficulty  of  returning  it.  If  in  any  case 
it  is  proper  to  return  it,  it  is  not  very  difficult  to  do  so.  An 
assistant  hooks  a  finger  of  each  hand  under  the  ends  of  the 
incision,  and  pulls  the  parietes  forwards  ;  the  surgeon  spreads 
both  hands  over  the  sponge  which  covers  the  bowels,  and  by 
steady  gentle  pressure  forces  their  contents  into  the  bowels 
inside  the  abdomen.  When  empty  and  collapsed,  the  extruded 
bowels  are  readily  returned. 

But  it  is  not  always  proper  to  return  distended  intestine  into 
the  abdominal  cavity.  I  hold,  on  the  contrary,  that  no  opera- 
tion for  intestinal  obstruction  is  properly  completed  if  the  patient 
leaves  the  operating  table  with  a  greatly  distended  abdomen. 
The  effects  of  distension  are  doubl}'  deleterious — on  the  system 
generally,  and  on  the  bowels  themselves.  That  dyspncea,  pal- 
pitation, and  what  may  be  called  abdominal  shock,  follow  great 
distension  of  the  abdominal  cavity  is  well  enough  known.  That 
paralysis  may,  and  does,  follow  over-distension  of  a  viscus  such 
as  intestine,  whose  contraction  depends  on  inorganic  muscle  in 
its  walls,  is  also  known.     But  it  is  not  generally  recognised  that 


ABDOMINAL   DISTENSION.  437 

the  mere  presence  of  an  excess  of  fluid  or  gas  in  the  intestine  is 
in  itself  an  efficient  cause  of  obstruction.  When  the  intestine, 
confined  by  mesentery  and  by  the  limits  of  the  abdominal  cavity, 
is  fully  distended,  it  does  not  form  gentle  curves,  but  acute 
flexures ;  at  these  flexures  the  intestinal  walls  on  the  mesenteric 
side  encroach  on  the  lumen,  so  as  to  form  valves  which  obstruct 
the  passage  of  contents.  Even  when  the  intestines,  artificially 
distended  in  the  deadhouse,  are  removed  from  the  cavity  with 
the  mesentery  attached,  and  laid  on  the  table,  they  do  not  empty 
themselves.  The  disappointing  results  of  simple  tapping  of  the 
bowels  are  thus  explained :  the  gut  is  emptied  down  to  the 
second  or  third  flexure,  and  no  further.  These  view^s,  founded 
on  observations  during  operations  and  on  experiments  in  the 
deadhouse,  have  recently  been  incidentally  confirmed  by  certain 
experiments  of  Senn  on  inflation  of  the  intestine  with  gas.  Of 
their  truth  and  of  their  importance  there  can,  I  think,  be  no 
question. 

Further  considerations  in  support  of  this  view  may  be 
brought  forward  in  the  practical  benefits  derived  from  Nelaton's 
operation  of  enterotomy  and  Kussmaul's  treatment  b}'  artificial 
emesis.  Many  cases  of  cure  b}^  enterotomy,  which  is  nothing 
more  than  drainage  of  intestinal  contents,  have  been  recorded. 
And  alread}'  a  considerable  number  of  cures  by  drainage  through 
the  oesophageal  tube  (Kussmaul's  plan)  have  accumulated. ■•' 
The  relief  that  vomiting  affords  is  evident  in  every  case  of 
intestinal  obstruction.  There  can  be  no  doubt  that,  as  Senn 
puts  it,  "great  distension  of  the  stomach  constitutes  an  import- 
ant factor  in  causing  or  aggravating  intestinal  obstruction,  as  it 
effects  compression,  which  again  causes  impermeability  of  the 
intestines,  or  aggravates  conditions  arising  from  an  antecedent 
partial  permeability,  by  producing  sharp  flexions  among  the 
distended  coils  of  the  intestines."  No  one,  experienced  in 
abdominal  surgery,  can  fail  to  have  observed  the  dangers  of 
distension,  or  to  have  appreciated  the  benefits  of  getting  rid  of 
intestinal  fluids. 

I  would  therefore,  in  every  case  of  laparotomy  for  intestinal 
*  See,  in  particular,  Rhen,  Ccntralbl.f.  Chir.,]\x\y  23rd,  1887. 


438  LAPAROTOMY  FOR   OBSTRUCTION. 

obstruction  with  distension,  consider  evacuation  of  the  intestinal 
contents  as  an  essential  part  of  the  proceeding. 

To  open  the  bowel,  it  is  best  to  make  an  incision  by  a  scalpel 
transversely  to  its  axis  at  the  point  most  distant  from  the 
mesentery.  A  trocar  and  cannula,  large  enough  to  permit  outflow 
with  sufficient  rapidity,  would  make  a  ragged,  bruised  wound,  not 
so  suitable  for  being  dealt  with  b}'  suture,  and  not  so  likely  to  heal 
kindly,  as  a  simple  incision.  The  bowel,  properly  protected,  is 
pulled  a  few  inches  away  from  the  wound,  and  held  over  a 
vessel  by  both  hands,  while  an  assistant  gently  kneads  the 
sides  of  the  abdomen  to  force  the  fluids  along  the  bowel  and  up 
to  the  opening.  The  first  flow  of  gas  and  liquid  rushes  out  with 
considerable  force,  and  a  notable  diminution  in  the  size  of  the 
abdomen  will  at  once  be  apparent  :  artificial  pressure,  however, 
is  wanted  to  empty  the  rest  of  the  bowels.  Of  course,  the  bowel 
that  had  been  constricted  will  have  been  carefully  examined  to 
see  that  there  is  no  chance  of  its  being  ruptured  in  the  manipu- 
lation. But  the  operation  having,  on  the  whole,  an  effect  of 
relieving  the  bowels  of  tension,  need  not  be  regarded  as 
endangering  the  continuity  of  the  intestinal  walls.  When  the 
bowel  is  sufficiently  empty,  the  opening  is  carefully  closed  by 
a  continuous  catgut  or  silk  suture,  including  only  peritoneum 
muscle  and  sub-muscular  fibrous  tissue,  in  the  ordinary  manner. 
In  three  cases  on  which  I  operated  in  this  way  I  used  a  double 
continuous  suture,  simply  repeating  the  process  with  the  same 
thread  in  the  opposite  direction.  Any  peritoneal  fluid  is  to  be 
mopped  out,  and  the  case  generall}'  treated  as  an  ordinar}' 
abdominal  section. 

Removal  of  the  Cause  of  Obstruction. — The  surgical  proceeding 
for  the  relief  of  the  constriction  varies  according  to  the  cause  of 
it.  In  most  cases  where  laparotom}'  is  performed,  the  removal 
of  the  cause  will  consist  in  the  division  of  a  band,  the  enlarge- 
ment of  an  opening  and  release  of  the  bowel,  the  untwisting  of  a 
volvulus,  or  the  drawing  out  of  an  intussusception.  In  all  it 
may,  as  already  indicated,  be  advisable  to  incise  the  bowel  and 
draw  off  its  contents.     But  in  some  cases  it  ma}' be  necessary  to 


OPERATION  IN    VOLVULUS.  439 

resect  a  piece  of  gangrenous  or  diseased  bowel — enterectomy. 
In  others  it  will  be  advisable  to  leave  an  intestinal  fistula — 
enterostomy  or  enterotomy.  These,  and  other  allied  special 
proceedings,  will  receive  separate  consideration.  Here  we  con- 
sider the  special  modes  of  proceeding  with  the  individual  forms 
of  constriction. 

In  Volvulus. — The  unravelling  of  a  volvulus  of  the  small 
intestine,  especially  if  it  is  caused  by  the  intertwining  of  two 
coils,  must  frequently  be  a  matter  of  considerable  difficulty. 
Volvulus  of  the  sigmoid  flexure  is  still  more  difficult  to  deal 
with.  At  an  autopsy  which  I  performed  on  a  case  of  volvulus 
of  the  caecum,  I  could  not,  though  the  incision  extended  from 
sternum  to  pubes,  undo  the  twist.  Mr.  Treves  has  had  a  similar 
experience  with  volvulus  of  the  sigmoid  flexure  during  the  life 
of  the  patient,  and  found  much  difficulty  in  righting  matters 
after  death.  In  another  case  on  which  I  operated,  I  was  able  to 
reduce  a  volvulus  of  the  caecum,  and,  with  the  aid  of  enterotomy, 
to  save  the  patient's  life.  In  a  second  case  on  which  I  operated 
in  the  Bristol  Infirmary,  a  volvulus  of  the  small  bowel  was 
found,  but  could  not  be  reduced  till  the  whole  was  removed  from 
the  abdominal  cavity.  The  bowel  was  twice  twisted  on  itself, 
and  when  uncoiled,  at  once  collapsed,  the  contents  flowing  down- 
wards. At  the  end  of  a  week,  symptoms  of  recurrence  of  the 
volvulus  appearing,  I  performed  enterotomy  without  chloroform, 
fixing  the  bowel  to  pieces  of  strapping  around  the  wound.  The 
patient  at  present  wears  a  catheter  in  the  opening,  through  which 
he  passes  flatus  along  a  tube  into  a  bottle  which  he  carries  in 
his  pocket.  At  the  end  of  a  year  or  so,  when  the  distended 
bowel  has  contracted,  he  will  probably  dispense  with  this 
catheter,  which  gradually  ceases  to  be  required.  The  rapid 
distension  of  the  gut  in  volvulus,  the  early  occurrence  of  peri- 
tonitis, and  the  complications  which  frequently  accompany  the 
condition,  sufficiently  explain  the  difficulty  met  with  in  reduc- 
ing it. 

Such  cases  left  to  themselves  are  hopeless,  and  a  strong  effort 
should  be  made  to  bring  success  to  the  operation.  As  soon  as  it 
is  evident  that  it  is  impossible  to  reduce  the  twist,  the  distended 


440  LAPAROTOMY  FOR   OBSTRUCTION. 

intestine,  pulled  out  through  the  incision,  ought  to  be  opened  at 
the  highest  part  of  the  curve,  and  emptied  of  its  contents.  After 
this,  reduction  ought  again  to  be  attempted.  If  it  succeeds,  the 
opening  in  the  bowel  may  be  sutured  and  the  abdominal  wound 
closed.  If  it  does  not  succeed,  an  artificial  anus  must  be  made 
in  the  first  convenient  piece  of  bowel  above  the  volvulus.  Re- 
section of  the  affected  gut  has  been  suggested  ;  but  such  a  pro- 
ceeding can  scarcely  be  contemplated  unless  the  volvulus  is 
small,  in  which  case  reduction  is  less  likely  to  fail. 

In  Strangulation  by  Bands  and  through  Apertures. — The  removal 
of  a  constriction  belonging  to  this  class  is  not  usually  a  difficult 
proceeding.  A  peritoneal  adhesion  may  be  readily  tied  in  two 
places  by  suitable  ligatures,  and  divided  between  them.  They 
ought  to  be  tied  as  close  as  possible  to  their  sites  of  attachment ; 
as,  if  they  are  left  long,  they  may  give  trouble  at  a  future  period. 
The  same  treatment  ought  to  be  applied  to  omental  cords :  they 
ought  to  be  tied  close  to  their  point  of  origin,  and  cut  off  short. 
If,  as  is  sometimes  the  case,  the  cord  is  very  thick,  it  may  be 
tied  by  transfixion  in  two  portions;  it  will  rarely  be  necessary  to 
tie  individual  vessels.  Sometimes  there  exists  a  second  band, 
causing  strangulation  ;  a  good  few  cases  are  recorded  where 
death  was  caused  by  an  overlooked  strangulation. 

In  dealing  with  a  Meckel's  diverticulum,  we  must  ascertain 
whether  we  are  dealing  with  bowel,  or  the  still  pervious  rudi- 
ment that  goes  to  the  umbilicus,  or  a  simple  inflammatory  band. 
The  band  is  treated  as  are  other  bands.  When  we  have  to  deal 
with  a  pervious  tube,  we  may,  according  to  its  size,  be  content 
with  mere  division  as  low  down  as  possible ;  or  we  may,  at  the 
end  next  the  bowel,  have  to  make  the  closure  as  carefully  as  we 
should  for  any  other  opening  into  the  bowel.  Though  there  is  a 
remote  danger  in  leaving  a  diverticulum,  there  may  be  a  still 
greater  immediate  danger  in  removing  one  if  it  is  large ;  and  its 
removal  involves  the  making  of  an  opening  of  a  considerable 
size.  It  ought  to  be  removed  at  a  point  where  it  is  perceptibly 
diminished  in  size.  The  best  mode  of  closure  would  probably 
be  by  pushing  inwards  the  mucous  membrane,  and  ligaturing 
the  fibrous  coat  outside  it.     If  the  opening  appears  to  be  too 


OPERATION   IN  INTUSSUSCEPTON.  441 

large  to  be  treated  in  this  way,  it  may  be  closed  by  the  Lembert 
suture,  or  any  other  plan  most  affected.  In  a  case  on  which  I 
operated  with  pervious  diverticulum  about  as  thick  as  a  crow- 
quill,  I  was  content  with  simple  ligature  and  careful  disinfection 
of  the  mucous  membrane. 

If  the  appendix  is  the  cause  of  constriction,  we  should  try, 
by  division  of  the  adhesions,  to  liberate  the  constricted  bowel. 
If  this  be  impossible,  the  appendix  itself  must  be  cut  through, 
and  closed  by  suturing  the  peritoneal  surfaces  after  having 
doubled  the  tube  inwards.  It  must  not  be  forgotten  that  the 
mesentery  (so  called)  of  the  appendix  sometimes  contains  a 
goodly  sized  vessel. 

The  Fallopian  tube,  adherent,  as  a  cause  of  strangulation, 
may  be  treated  as  a  simple  band,  and  divided  as  such  with 
safety;  though,  as  in  other  cases,  it  is  better  to  try  and  limit  the 
division  to  the  inflammatory  new  tissue. 

In  all  such  cases,  the  gut  will  be  carefully  examined  before 
the  abdomen  is  closed.  If  it  is  much  distended,  it  will  be  incised 
and  emptied  at  some  distance  from  the  site  of  constriction  ;  if  it 
is  gangrenous  or  on  the  point  of  becoming  perforated,  this  part 
must  be  excised  in  a  manner  to  be  described. 

In  Intussusception. — In  most  cases  diagnosed  as  intussuscep- 
tion, a  full  trial  to  insufflation,  injection  of  fluids,  or  some  such 
means,  will  have  been  instituted,  before  abdominal  section  is 
thought  of.  It  seems,  from  Treves's  investigations,  that  spon- 
taneous cure  by  separation  of  the  gangrenous  intussusception  is 
a  very  rare  event  indeed;  and  cure,  after  any  plan  not  operative, 
would  seem  to  take  place  with  far  less  frequency  than  is  popu- 
larly supposed.  With  early  operation,  laparotomy  for  intus- 
susception, involving  as  it  does  nothing  more  than  merely 
pulling  out  the  intussusceptum,  ought  to  be  one  of  the  most 
successful  of  abdominal  operations  :  when  postponed  till  adhe- 
sions have  formed,  and  a  large  amount  of  gut  has  become 
invaginated,  it  may  be  impossible  to  reduce  it.  In  51  operations 
collected  by  Braun,  attempts  to  reduce  the  intussuscepted  gut 
succeeded  in  26,  and  failed  in  25  ;  and  16  of  these  26  cases  sub- 
sequently died.     Operation  should  not  be  delayed  beyond  the 


442  LAPAROTOMY  FOR   OBSTRUCTION. 

second  day.  At  an  autopsy,  it  will  be  usually  found  that  the 
bowel  will  give  way  before  the  intussusceptum  is  pulled  out.  I 
have  failed  at  operation  to  reduce  a  very  large  intussusception 
of  three  da3's'  standing  in  a  child  a  year  old. 

For  reduction,  the  entering  bowel  ought  to  be  grasped  as 
closely  as  possible  to  the  invagination,  and  the  other  fixed  point 
ought  to  be  the  bowel  just  beyond  the  end  of  the  intussusceptum ; 
with  traction  is  associated  a  gentle  process  of  kneading.  To 
catch  the  edge  of  the  intussuscipiens  close  to  the  entrance, 
would  be  to  force  it  down  on  itself  and  cause  compression  of  the 
intussusceptum,  and  thereby  increase  the  difficulty  of  reduction. 
The  reduced  bowel  must  be  scrutinised  most  carefully,  to  see 
that  there  is  no  laceration  or  gangrene. 

If  the  intussusception  cannot  be  reduced,  three  plans  are 
open  :  firstly,  resection  of  the  whole  with  suturing  of  the  divided 
bowels ;  secondly,  resection,  and  the  formation  of  an  artificial 
anus  ;  thirdly,  formation  of  an  artificial  anus,  without  resection. 
A  fourth  plan  which  has  been  recommended  is  to  form  an 
artificial  anastomosis  between  two  portions  of  bowel  above  and 
below  the  intussusception.  The  first  can  be  done  only  where 
the  intussusception  is  comparatively  small,  not  involving  more 
than  three  or  four  feet  of  bowel;  the  second,  usually  preferable  to 
the  first,  is  similarly  limited  in  application ;  the  third  may  be  used, 
as  a  last  chance,  where  neither  resection  nor  reduction  is  possible. 
The  fourth  plan,  of  exclusion  of  the  intussusception,  and  anas- 
tomosis of  bowel  above  and  below  the  obstruction,  would  be 
facilitated  by  the  use  of  Senn's  decalcified  bone  plates  or  some 
similar  contrivance.  In  an  infant  on  whom  I  operated,  where  quite 
half  of  the  small  bowel  lay  inside  the  colon  and  could  be  felt 
through  the  anus,  resection  was,  of  course,  out  of  the  question. 
I  made  an  artificial  anus  above,  and  fixed  the  bowel  with  catch- 
forceps,  so  that  more  might  not  be  dragged  into  the  wound.  A 
better  plan  would  perhaps  have  been  to  divide  the  gut,  close  the 
lower  part,  and  leave  it  to  its  fate  with  the  intussusception, 
while  the  upper  end  was  taken  out  of  the  wound  as  an  artificial 
anus.  Such  a  proceeding,  of  course,  would  be  advisable  only  if 
the  invagination  were  low  down.     The  prognosis  after  such  pro- 


OPERATION   FOR   FOREIGN  BODIES.  443 

ceedings  must  always  be  bad  :  all  the  greater  necessity  for  early 
operation. 

Prof.  Braun  of  Jena*  has  classified  63  cases  of  operation  for 
invagination.  For  disinvagination  the  operation  was  performed 
51  times :  of  these,  11  were  cured  and  40  died ;  30  were  children, 
21  were  adults.  Of  10  cases  in  which  enterectomy  was  performed, 
all  died.  After  disinvagination  failed,  resection  was  performed 
12  times  without  a  single  success;  enterotomy  9  times,  also 
without  a  success.  Disinvagination  alone,  therefore,  would  seem 
to  offer  hopes  of  success;  and  this  must  be  attempted  very  early. 

Intussusception  of  the  rectum  may  be  treated  locally  without 
the  performance  of  abdominal  section.  Barkerf  has  resected 
an  invaginated  adenoid  epithelioma  of  the  rectum  successfully, 
after  stitching  the  divided  walls  of  the  gut  together.  Verneuii 
and   Hulenkampj  had  previously  done  the  same  operation. 

In  Foreign  Bodies. — It  may  be  possible  to  pass  these  along 
when  the  abdomen  is  opened,  so  that  opening  of  the  gut  may  be 
unnecessary.  If  this  cannot  be  done,  the  bowel  must  be  opened, 
and  the  substance  extracted.  If  the  gut  overlying  the  substance 
seems  to  be  but  slightly  inflamed,  it  may  be  opened  immediately 
over  it,  and  the  material  extracted  with  ease.  If  the  bowel  is 
inflamed,  as  will  usually  be  the  case,  it  will  be  wise  to  make  the 
opening  a  little  above  the  site  of  the  obstruction,  in  the  dilated 
and  healthy  intestine.  The  opening  must  be  of  sufficient  dimen- 
sions to  permit  of  the  extraction  of  the  foreign  body  without 
causing  laceration.  By  preference  the  line  of  incision  would  lie 
in  the  long  axis  of  the  bowel,  at  its  free  margin.  If  the  body 
cannot  easily  be  pushed  up  to  the  opening,  the  opening  may  be 
pushed  down  to  the  body.  It  may  be  of  advantage  to  crush  or 
compress  the  body  before  attempting  to  extract  it.  The  intes- 
tinal contents  may  or  may  not,  according  as  seems  most  con- 
venient, be  permitted  to  escape  before  removing  the  cause  of 
obstruction.  During  the  manipulations,  scrupulous  care  will  be 
observed  to  prevent  the  escape  of  faeces  into  the  abdomen.  If  the 
bowel  is  seriously  damaged  by  inflammation  or  ulceration,  or  looks 
gangrenous,  the  advisability  of  resection  must  be  contemplated. 

*  Archill,  f.  Chir.,  Bd.  xxxiii,  Hft.  2.         t  Lancet,  May  14th,  1878. 
I  Internat.  Journ.  Med.  Sc,  October,  1887,  p.  529. 


Enterotomy. 

The  name  Enterotomy  is  given  to  the  operation  of  making, 
by  peritoneal  section,  an  opening  in  the  bowel  through  which 
its  contents  may  be  discharged.  The  best  name  for  this  is 
obviously  Enterostomy,  but  usage  has  justified  the  use  of  the 
former  term. 

Enterotomy,  first  performed  on  a  patient  of  Trousseau's  by 
Nelaton,  and  often  known  as  Nelaton's  operation,  is  most  pro- 
perly regarded  as  an  inevitable  and  undesirable  substitute  for 
other  and  better  proceedings.  Nelaton  advocated  it  as  a  plan 
of  treating  cases  of  intestinal  obstruction  which  had  lasted  over 
six  or  eight  days,  in  which  there  was  great  abdominal  disten- 
sion, and  where  there  was  faeculent  vomiting.  Other  surgeons 
have  performed  the  operation  on  Nelaton's  principles,  and  with 
a  gratifying  measure  of  success — so  far,  at  least,  as  immediate 
results  are  concerned.  As  it  does  not  attack  the  cause  of  the 
illness,  and  is,  consequently,  rarely  other  than  palliative,  it 
ought  never  to  be  instituted,  except  in  cases  where  other  and 
more  complete  measures  are  unavailable.  It  should  never  be 
undertaken  unless  there  is  fairly  conclusive  evidence  that  the 
obstruction  is  either  low  down  in  the  small  bowel,  or  in  some 
part  of  the  large  bowel  that  is  beyond  the  reach  of  colotomy. 

The  operation  is  a  very  simple  one.  Entrance  is  effected  in 
the  right  iliac  or  inguinal  region,  parallel  to  and  a  little  above 
Poupart's  ligament,  between  the  anterior  iliac  spine  and  the 
epigastric  artery.  The  incision  need  not  be  a  long  one ;  one 
and  a  half  to  two  or  three  inches,  according  to  the  thickness  of 
the  abdominal  walls,  being  sufficient.  The  nearest  distended 
piece  of  bowel,  usually  some  portion  of  the  lower  part  of  the 
ileum,  is  drawn  into  the  wound,  and  fixed  there  by  sutures.  If 
the  case  is  not  urgent  the  bowel  need  not  be  opened  at  once, 
but  left  there  for  two  or  three  days  till  adhesions  have  formed. 
It  must  not  be  forgotten  that  if  faeces  escape,  they  run  into  the 
peritoneal  cavity ;    and  seeing  that  delay  in  opening,  even  for  a 


ENTEROTOMY.  445 

few  hours,  might  secure  the  formation  of  plastic  lymph  suffi- 
cient to  close  the  opening,  wherever  it  is  possible  such  delay 
may  advantageously  be  observed.  If  it  is  decided  not  to  open 
the  bowel  at  once,  mere  fixation  by  a  couple  of  harelip  pins,  or 
by  two  silk  or  silver  sutures,  passing  through  the  fibrous  coats 
only,  will  be  all  that  is  required.  Some  recommend  simply 
leaving  the  bowel  in  the  wound,  in  the  certainty  that  adhesions 
will  soon  take  place  without  the  insertion  of  any  sutures.  If  it 
is  decided  to  open  the  bowel  at  the  time,  we  must  secure  very 
accurate  co-aptation  between  the  intestinal  walls  and  the  edges 
of  the  wound  before  making  the  opening.  Here  there  is  more 
abdominal  movement  than  in  colotomy,  and  the  opening  is  into 
the  peritoneal  cavity,  so  that  the  danger  of  faecal  escape  is 
greater.  Two  silver  sutures,  not  thin  enough  to  cut,  are  usually 
recommended  as  the  main  support ;  but  two  or  four  additional 
silk  sutures  should  be  inserted.  It  matters  little  how  the 
apposition  is  obtained,  provided  it  be  accurate  and  abiding. 
On  two  occasions  I  got  perfect  union  from  the  application  of 
a  continuous  suture  including  skin,  peritoneum,  and  outer 
coats  of  bowel.  In  two  other  cases  the  bowel  was  simply  fixed 
in  the  wound  by  loops  of  silk  attached  to  strapping  on  the 
parietes.  When  sutured  satisfactorily,  the  intestine  is  incised 
by  a  tenotomy  knife,  a  very  small  opening  being  made. 

In  a  few  da3^s  the  abdominal  wound  will  probably  have 
healed,  and  a  faecal  fistula  will  have  formed.  It  will  depend 
upon  the  nature  of  the  case  whether  we  seek  later  on  to  cure 
this  artificial  anus.  In  cases  of  unremovable  cancer,  for  which 
chiefly  this  proceeding  is  indicated,  any  further  operation  would 
not  be  contemplated.  In  cases  of  faecal  accumulation  where 
enterotomy  had  been  performed,  the  question  of  closure  of  the 
fistula  would  arise  as  soon  as  the  tendency  to  accumulation  had 
passed  off.  In  some  few  cases,  where  enterotomy  is  per- 
formed to  relieve  the  patient  of  very  urgent  symptoms  when 
diagnosis  was  wrong  or  more  perfect  treatment  was  impossible, 
the  subsidence  of  acute  intestinal  troubles  and  further  infor- 
mation as  to  the  cause  of  the  disease  might  make  us  contem- 
plate closure  of  the  fistula.     In  most   cases,  however,   it  will 


446  ENTEROTOMY. 

remain  as  an  artificial  anus,  prolonging  life  and  relieving  suffer- 
ing, but  not  curing  the  disease.  Dr.  Malins"^'  has  twice  per- 
formed laparo-enterotom}^  for  obstruction  by  adhesions  in  the 
pelvis  which  he  could  not  completely  divide ;  and  in  each  case 
the  patient  recovered,  with  a  faecal  fistula. 

When  the  first  incision  has  been  made  in  the  middle  line, 
and,  after  exploration,  the  cause  of  obstruction  cannot  be  found 
or  cannot  be  overcome,  enterotomy  may  be  performed  at  this 
situation.  In  fact,  as  a  last  resource  after  failure  of  other 
methods,  enterotomy  will  most  frequently  fall  to  be  performed 
in  the  middle  hne.  In  this  case  accurate  suturing  by  a  con- 
tinuous suture  to  the  skin,  and  immediate  opening  of  the  bowel, 
will  be  carried  out.  If  the  parietes  are  not  very  thick,  the 
parietal  peritoneum  may  be  pulled  outwards  and  fixed  to  the 
wound-margins.  The  continuous  suture  is  placed  in  two  por- 
tions, and  their  extremities  tied  together  after  being  stitched 
into  the  parietal  wound.  In  a  successful  case  of  enterotomy,  I 
thought  the  insertion  of  a  piece  of  drainage  tubing  into  the 
opening  in  the  bowel  maintained  accurate  co-aptation  of  the 
uniting  surfaces,  and  helped  to  prevent  contamination  by 
faeces. 

For  the  treatment  of  very  bad  cases  of  intestinal  obstruction 
of  long  standing,  I  have  urged  the  adoption  of  enterotomy 
performed  under  local  anesthesia  by  subcutaneous  injection 
of  cocaine  at  the  site  of  incision.  In  this  sense  the  operation 
is  merely  temporary  or  preliminary,  intended  to  ward  off  death 
where  the  full  operation  to  relieve  the  cause  of  obstruction  could 
not  be  borne,  and  to  permit  the  patient  to  recover  strength 
sufficiently  to  bear  the  major  operation.  As  the  aim  of  every 
surgical  operation  is  to  save  life,  all  other  motives  must  be  made 
subservient  to  this  chief  end.  In  many  cases  a  prolonged  or 
scientifically  complete  operation  under  anaesthesia  is  little  less 
than  a  warrant  of  death ;  for  such  a  proceeding,  occupying  in 
skilful  hands  five  minutes  at  most,  and  not  involving  anaesthesia, 
may  save  the  patient's  life. 

•  Brit.  Mai.  Joimu,  Feb.,  1S83,  p.  381. 


Colotomy. 

By  colotomy  is  meant  the  establishment  of  a  fistula  in  the 
colon,  ascending  or  descending,  by  an  opening  in  that  part  of 
the  bowel  which  is  uncovered  by  peritoneum  and  lies  in  contact 
with  the  parietes. 

History. — Colotomy  was  first  proposed  b}'  Littre,  in  1710.-'' 
His  proceeding  was,  to  open  the  sigmoid  flexure  of  the  colon 
by  incision  through  the  abdominal  walls  in  the  left  inguinal 
region.  It  was  suggested  for  imperforate  anus  in  children.  It 
is  not  probable  that  Littre  ever  actually  performed  the  opera- 
tion ;  and  his  suggestion  was  forgotten  till  1776,  when  Pillore  of 
Rouen  operated,  but  by  a  different  method.  He  opened  the 
caecum  by  a  parietal  incision  made  in  the  right  inguinal  region. 
Twenty  years  later  Callisen  suggested  an  operation  whereby  the 
colon  might  be  opened  without  entering  the  peritoneal  cavity. 
He  sought  to  expose  the  bowel  where  it  was  not  covered  by 
peritoneum  by  a  vertical  incision  in  the  left  lumbar  region.  He 
failed  to  do  this  on  the  dead  subject,  and  he  never  attempted  it 
on  the  living.  Fine  of  Geneva,  in  1797,  made  an  opening  in 
the  transverse  colon  through  an  incision  in  the  region  of  the 
umbilicus.  Amussat,  driven  to  think  of  it  while  he  was  attend- 
ing the  famous  Broussais  for  cancer  of  the  rectum,  actually 
performed  the  retro-peritoneal  operation.  He  operated  on  the 
right  side  b}^  a  transverse  incision.  In  the  two  following  years 
he  operated  six  times,  with  five  successes.  In  1842  Ashmead  of 
Philadelphia,!  not  aware  of  Callisen's  proposal,  performed  a 
retro-peritoneal  lumbar  colotomy  by  a  vertical  incision  on  the 
left  side. 

The  operation,  as  usually  performed  now,  is  a  combination 
of  the  methods  of  Callisen  and  Amussat.  Like  Calhsen's,  it  is 
done  on   the  left  side ;    and,  like  Amussat's,  it   is  carried  out 

*  Mem.  Acad,  Sc.  Paris,  vol.  x.,  p.  36. 
t  Trans.  Coll.  Pliys.  Phila,,  vol.  i.,  p.  99,  1842. 


448  COLOTOMY. 

through  an  incision  which  is  either  transverse  or  obliquely 
transverse.  The  oblique  incision,  first  recommended  by 
Bryant,*  is  that  now  adopted  by  most  surgeons. 


CONDITIONS    INDICATING    OPERATION. 

Colotomy  may  be  performed  for  any  condition  which 
obstructs  the  passage  of  faeces  along  the  colon,  or  under  any 
circumstances  in  which  it  is  advisable  to  place  that  bowel  at 
rest.  Obstruction  may  be  produced  by  various  causes  ;  such 
as,  cancer  of  the  rectum  or  sigmoid  flexure  or  any  other  part  of 
the  colon  ;  tumours  of  the  peritoneum  or  any  abdominal  organ, 
pressing  on  the  bowel ;  volvulus  of  the  sigmoid  flexure  or  of 
the  caecum  and  ascending  colon  ;  and  faecal  accumulations  and 
collections  of  foreign  matter  which  cannot  be  disturbed  by  other 
means.  It  may  be  called  for  in  cases  of  incurable  ulceration  of 
the  bowel,  however  induced,  when  we  have  reason  to  believe 
that  irritation  of  faeces  and  unrest  of  the  intestinal  walls  con- 
tribute to  the  continuance  of  the  disease ;  and  in  cases  of 
extreme  dilatation,  with  atony  of  the  colon,  giving  rise  to 
frequent  attacks  of  obstruction. 

The  operation  may  be  considered  from  three  points  of  view  : 
(i)  as  a  curative  measure,  (2)  as  a  measure  intended  to  ward  off 
for  a  time  impending  death,  (3)  as  a  proceeding  intended,  in  the 
absence  of  immediate  danger  to  life,  to  add  to  the  comfort  of 
the  patient  and  prolong  his  existence. 

As  a  curative  measure,  colotomy  may  be  performed  in  cases 
of  ulceration  of  the  rectum,  simple  or  specific,  when  all  other 
measures  have  failed  ;  in  excessive  distension,  with  atony  of  the 
colon ;  in  volvulus  of  the  sigmoid  flexure,  and  in  recto-vesical 
fistula. 

In  ulceration  of  the  rectum,  the  condition  may  be  kept  up 
or  aggravated  by  the  irritation  of  passing  faeces  and  by  the 
spasmodic  contractions  of  the  hyperaesthetic  bowel.  B3' 
making  an  artificial  anus  above  the  ulcerated  part,  the  bowel 
is  set  at  rest,  and  the  faeces  do  not  come  into  contact  with 
*  Trans.  Med.-Chir.  Soc,  vol,  xxxv.,  p.  99. 


INDICATIONS   FOR    OPERATION.  449 

the  ulcerated  mucous  membrane.  In  most  cases  it  will  be 
sufficient  to  operate  on  the  left  side  ;  but  if  we  suspect  that 
the  ulceration  extends  higher  up  than  the  sigmoid  flexure,  it 
will  be  better  to  operate  on  the  right  side. 

In  cases  of  excessive  distension  of  the  colon  with  atony  of 
its  walls,  where,  in  spite  of  strong  purgation  and  the  adminis- 
tration of  enemas,  faeces  accumulate  and  symptoms  of  obstruc- 
tion frequently  appear,  right  colotom}/  is  indicated.  By  giving 
an  exit  to  the  faeces  at  the  commencement  of  the  colon,  the 
bowel  is  kept  empty,  and  has  an  opportunity  of  contracting  and 
regaining  its  tone.  From  being  a  flaccid  tube  with  no  power  of 
spontaneous  contraction  and  an  almost  unlimited  capacity  for 
distension,  it  will,  in  the  course  of  a  few  weeks'  rest  and  freedom 
from  distension,  regain  its  functions  as  a  contractile  viscus  of 
limited  calibre. 

For  volvulus  of  the  sigmoid  flexure,  Bryant  recommends 
colotomy  as  a  remedial  measure.  There  is  much  to  be  said  in 
favour  of  the  proceeding  for  this  condition.  As  compared  with 
laparotomy,  it  is  not  theoretically  so  perfect  ;  but  we  have 
already  seen  that  laparotomy  in  volvulus  is  not  likely  to  be 
practically  successful  in  every  sense,  and  that  it  will  probably 
result  in  the  formation  of  artificial  anus.  Whatever  advantages 
accrue  from  the  retro -peritoneal  operation  are  in  favour  of 
colotomy :  these  are,  probably  less  severity  in  the  operation 
itself ;  avoidance  of  the  risk  of  escape  of  faeces  into  the 
abdomen,  which,  with  the  enormous  collections  that  are 
usually  found  in  these  cases,  must  be  considerable ;  and 
greater  facility  in  operating.  But  each  case  must  be  decided 
on  its  merits. 

In  cases  of  recto-vesical  fistula  which  have  lasted  for  some 
time,  colotomy  gives  the  only  chance  of  cure  short  of  resection. 
The  faeces  passing  through  the  opening  in  the  colon,  no  longer 
traverse  the  fistula,  the  rectum  collapses,  and  the  fistula  spon- 
taneously closes.  The  presence  of  severe  cystitis,  the  frequency 
with  which  attacks  of  retention  of  urine  appear,  the  condition 
of  the  patient,  and  various  other  circumstances,  will  in  each 
case  promote  or  restrain  the  advisability  of  operation. 

30 


450  COLOTOMY. 

As  a  measure  intended  to  ivard  off  wiminent  death,  colotomy  is 
called  for  in  all  cases  of  obstruction  in  the  colon,  from  whatever 
cause  arising.  The  great  majority  of  such  cases  are  examples 
of  cancer  of  the  rectum.  The  condition  of  the  patient  must  in 
every  case  settle  the  justifiability  of  the  operation.  If  the 
patient  is  evidently  so  near  death  from  the  disease  that  relief 
of  the  obstruction  can  prolong  life  only  for  a  week  or  two  at 
most  it  will  be  wise  to  let  nature  have  its  way.  The  choice 
between  a  death  from  obstruction,  and  a  death  from  exhaustion 
interrupted  by  the  horrors  of  a  serious  operation,  is  a  choice  of 
evils  nearly  equal.  But  if  the  obstruction  comes  on  in  the 
earlier  stages  of  the  disease,  when  the  patient  is  not  greatly 
weakened,  and  when  a  successful  result  to  the  operation  means 
not  only  escape  of  death  from  obstruction  but  prolongation  of 
life,  with  increase  of  comfort,  then  the  operation  is  clearly 
indicated. 

The  indications  in  other  forms  of  obstruction  from  growths 
which  are  not  removable — either  in  the  gut  itself,  or  invading 
or  pressing  upon  it  from  the  outside — are  similar  to  those  for 
cancer  of  the  rectum. 

It  has  been  said  that  an  operation  which  is  not  intended  to 
cure  the  disease,  and  which  places  the  patient  in  a  condition 
which  "  must  inevitably  render  him  an  object  of  disgust  to 
himself  and  of  loathing  to  everyone  around,"  ought  never  to  be 
performed.  The  inevitable  result  of  the  operation  need  not  be 
revolting  ;  properly  managed,  it  need  cause  little  more  than 
discomfort.  I  have  operated  on  a  lady  for  cancer  of  the  rec- 
tum, who  was  able  for  months,  not  only  to  dine  at  table,  but 
to  attend  dinner  parties.  And  even  if  the  result  were  revolting, 
and  the  patients'  sufferings  were  such  that  they  would  wish 
to  die,  it  is  still  our  duty,  according  to  the  highest  ethics, 
to  do  all  that  we  can  to  encourage  them  and  to  help  them 
to  live. 

As  an  Ameliorative  Proceeding  in  cases  of  Malignant  Disease 
where  there  are  no  symptoms  of  obstruction,  and  where  it  is 
intended  to  give  relief  to  the  patient  from  the  irritation  pro- 
duced by  the  passage  of  faeces  over  the  growth,  and  to  remove 


MORTALITY,  451 

from  the  growth  itself  this  source  of  harm,  colotomy  is  more 
open  to  discussion.  The  progress  of  cases  for  which  the  opera- 
tion, under  these  conditions,  has  been  performed  is  notoriously 
uncertain.  I  have  operated  on  a  case  in  which  there  were 
no  signs  of  obstruction,  and  in  whom  a  likelihood  of  pro- 
longed life,  with  increased  comfort,  was  predicted :  the  patient 
died  suddenly,  of  haemorrhage  from  the  growth.  In  another, 
weaker  constitutionally,  and  with  a  much  larger  growth, 
life  was  prolonged  for  more  than  a  year,  and  the  patient 
died  of  extension  of  the  growth  to  the  peritoneum.  Cases, 
again,  are  recorded  where  decided  improvement  sets  in, 
and  continues  for  some  time,  where  no  operation  has  been 
performed. 

Statistics  give  us  no  help  in  forming  an  estimate  of  the 
duration  of  life  in  such  cases,  with  and  without  operation. 
I  think  it  is  doubtful  if  surgeons  as  a  rule  follow  the  out- 
spoken advice  of  Bryant,  to  operate  as  soon  as  malignant 
disease  is  discovered  ;  and  much  might  be  said  in  support 
of  their  practice  —  at  all  events,  it  cannot  unreservedly  be 
condemned.  The  patient  ought  to  have  an  opportunity  of 
deciding :  in  my  experience,  the  .decision  is  usually  against 
operation. 

For  Inipcvfovate  Anus,  the  operation  holds  a  special  position. 
It  is  intended  to  ward  off  death,  but  it  may  or  may  not  be 
regarded  as  a  cure  for  the  disease.  In  many  cases,  it  is  the 
first  step  in  the  process  of  cure.  In  every  infant  born  with 
imperforate  anus,  an  operation  of  a  local  nature  is  first 
attempted ;  if  this  fails,  colotomy  by  some  method  is  per- 
formed, to  ward  off  death:  later  on,  an  attempt  may  be  made 
to  get  the  bowel  to  discharge  through  the  anus. 


Mortality.  Appreciation.  Choice  of  Method. — The  most  com- 
plete and  elaborate  statistics  on  colotomy  which  have  as  yet 
been  published  are  those  collected  by  Dr.  W.  R.  Batt.*  He 
records  351  operations;  of  these,  215  (62  per  cent.)  recovered, 

Amcr.  Journ.  Med.  Sc,  Oct.,  1884. 
30  * 


452  COLOTOMY. 

and  132   (38  per  cent.)   died, — 4  having  unknown  result.     The 
mortahty  after  the  various  methods  was: 

Operations.  Recovered.  Died.     Unknown. 

After  Amussat's  method  244  165(6870)  77  (31-6  %)  2 
„      Littre's            „             82  38(47Vo)  43(53-iVo)       i 

,,      Calhsen's         ,,  10  2  7  i 

In  Linea  Alba      4  4  —  — 

These    results    tally    in    a    remarkable    manner   with   those 

found  in  another  notable  collection  by  Van  Erckelens.  ■■'■     He 

brought  forward    262   cases   of  colotomy,  with   151    recoveries 

and  log  deaths. 

Operations.         Recovered.  Died. 

Amussat's  method      ...         165  102(62%)         63(38%) 

Littre's  „  ...  84  45  (53  7o)         39  (464  7o) 

If  these  statistics  can  be  taken  as  trustworthy,  they  would 
seem  to  indicate  an  improvement  in  the  mortalit}'  of  something 
like  ten  per  cent,  in  the  five  years  preceding  1884. 

Many  facts  of  interest  and  importance  which  cannot  be 
referred  to  here  are  worked  out  in  Dr.  Bait's  paper.  The 
mortality  after  all  operations  for  malignant  disease  was  found 
to  be  a  little  over  30  per  cent.  Amussat's  method  gave  a 
mortality  of  just  over  25  per  cent. ;  Littre's  gave  45  per  cent. 
If  it  is  proper  to  reason  from  the  results  of  these  old  operations, 
there  is  therefore  a  20  per  cent,  probability  of  success  in 
favour  of  retro-peritoneal  colotomy.  Of  52  operations  for 
imperforate  anus,  more  than  half  died ;  and  the  chance  of 
recovery  is  about  equally  balanced  between  the  two  methods. 
Of  20  operations  for  fistula,  all  recovered  save  two.  Of 
40  operations  for  obstruction,  one  half  died;  the  best  results 
being  got  from  Amussat's  operation.  Of  72  for  stricture,  43 
per  cent,  died,  also  with  better  results  by  Amussat's  method. 

Of  those  cases  which  recovered  from  operations  for  malignant 
disease,  12  died  within  6  months,  15  died  between  the  6th  and  12th 
month  ;    10  died  between  the  ist  and  2nd  year  ;  8  died  between 
the  2nd  and  3rd  years,  and  i  died  at  the  end  of  4^-  years. 
*  Langenbeck's  Arcliiv.,  1879,  p.  41. 


CHOICE  OF  METHOD. 

T.  ..^ix  .1.-^  ^^  ocen  that,  under  ever}^  circumstance,  favour- 
able or  otherwise,  colotomy  is  not  a  very  deadly  operation. 
Mere  statistics  cannot,  however,  give  a  just  estimate  of  the 
mortality.  Many  operations  are  performed  when  the  patient 
is  in  extremis;  and  in  these  the  result  is  tabulated  as  failure, 
even  if  the  patient  lives  for  ten  days  or  a  fortnight  in  com- 
parative comfort.  To  class  such  cases  with  others  in  which 
the  operation  is  performed  while  the  patient  is  in  fair  condition, 
adds  to  the  mortality  of  the  operation  unjustly.  The  conditions 
under  which  the  operation  is  performed  are  so  varied,  and 
even  divergent,  that  the  comparison  of  figures  is  of  little 
value,  except  as  affording  means  of  comparison  between 
different   operations. 

The  figures  show  distinctly  a  preponderating  bias  in  favour 
of  Amussat's  method — or  rather,  the  modern  modification  which 
goes  by  his  name.  Amussat's  method,  as  now  understood,  is 
retro-peritoneal  colotomy  performed  on  the  left  side  by  an 
oblique  incision  between  the  ribs  and  the  crest  of  the  ilium. 
It  is  the  combined  proceeding  of  Amussat,  Callisen,  and 
Br3^ant.  When  the  choice  is  given,  this  method,  as  affording 
the  best  chances  of  success,  ought  always  to  be  selected. 

For  imperforate  anus,  Littre's  method,  of  dividing  the 
parietes  in  the  left  inguinal  region  and  entering  the  peritoneum, 
has  much  in  its  favour.  With  imperforate  anus  are  frequently 
found  other  malformations  of  the  colon  which  would  render 
colotomy  impossible  by  the  retro-peritoneal  method.  Indeed, 
to  render  the  chances  of  success  in  completing  colotomy  most 
certain,  it  is  doubtful  whether  the  median  incision  would  not  be 
best  of  all.  The  distended  bowel  can  be  brought  to  the  middle 
line  either  from  the  right  or  the  left  side :  if  the  descending 
colon  exists,  it  may  be  opened ;  if  it  does  not  exist,  the  as- 
cending colon  may  be  opened  ;  and  if,  as  sometimes  happens,  the 
distended  rectum  is  median  in  position,  the  advantages  of  the 
median  incision  will  be  most  conspicuous.  Frequently  the  situ- 
ation of  the  bowel  may  be  located  by  percussion  and  palpation. 

As  the  names  given  to  the  operation,  following  the  proper 
names  of  individual  surgeons,  have  already  lost  their   signifi- 


COLOTOMY. 


cance  and   have   caused   a  good  deaToriTmifCTsion,  it  wilL.. 

convenient  to  speak  of  the  retro-peritoneal  method  as  Lumbar 
colotomy  ;  and  of  the  methods  in  which  the  abdominal  cavity  is 
entered,  as  Laparo-colotomy. 

THE    OPERATION    OF    LUMBAR    COLOTOMY. 

By  Lumbar  Colotomy  is  meant  the  making  of  an  opening  in 
the  colon,  ascending  or  descending,  on  either  side  of  the  body, 
within  that  area  where  it  is  not  covered  by  peritoneum,  and 
where  it  is  attached  to  the  abdominal  walls  by  cellular  tissue. 
The  opening  is  made  through  an  incision  in  the  lumbar  region 
— that  is,  in  the  space  bounded  by  the  last  rib  above,  and 
the  crest  of  the  ilium  below,  and  lying  within  lines  drawn 
vertically  between  the  middle  of  the  iliac  crest  and  the  last 
ribs  in  front,  and  the  lumbar  group  of  muscles  behind. 
Dividing  the  space  vertically  is  the  edge  of  the  quadratus 
lumborum  and  the  fascia  transversalis.  At  the  bottom  of  the 
space  lies  the  colon,  in  its  upper  part  overlapping  the  kidney ; 
in  its  lower  part  lying  in  contact  with  the  abdominal  wall,  and 
attached  to  it  by  cellular  tissue.  (See  Fig.  ^5,  8  &  18.)  The 
area  of  contact  varies  in  extent  with  the  amount  of  distension  of 
the  bowel.  In  full  distension  the  bowel  glides  under  the  peri- 
toneum, displacing  it  laterally,  so  that  the  surface  in  contact 
with  the  parietes  is  broadened.  When  the  bowel  is  contracted, 
the  peritoneum  enfolds  it  more  or  less  completely  according  to  the 
length  of  the  mesentery.  It  is  alwaj's  possible  to  separate  the 
collapsing  peritoneal  folds,  even  when  the  bowel  is  empty,  and  so 
reach  the  bowel  without  entering  the  peritoneal  cavity.  It  must  be 
noted  that,  according  to  Treves's  investigations,  there  is  more 
likelihood  of  a  mesentery  being  found  on  the  left  than  on  the 
right  side. 

The  best  practical  guide  to  the  site  of  the  bowel  is  that  fur- 
nished by  Allingham,  as  a  result  of  numerous  dissections.  It 
will  be  found  directly  under  a  point  marked  on  the  skin  about 
half  an  inch  behind  the  middle  of  the  crest  of  the  ilium,  as 
measured  between    its   anterior  and  posterior    spmes.      It  has 


THE   OPERATION. 


455 


been  recommended  that  this  point  be  marked  on  the  skin  in  ink. 
But,  as  a  matter  of  fact,  when  the  muscles  have  been  divided 
the  forefinger  is  the  best  guide. 

The  obhque  incision  recommended  by  Bryant  is  the  best. 
Its  chief  advantage  is,  that  it  gives  more  room  for  its  length 
than  do  other  incisions.      Further  claims  in  its  favour  are,  that 


Fig.   SS'      (After  Braune.) 

Transverse  Section  through  the  Navel  to  shoiv  the  parts  concerned  in  Colotomy. 

I.  Umbilicus.  2.  Rectus  Muscle.  3.  Great  Omentum.  4.  U'-eter.  5.  Transversalis 
Muscle.  6.  Internal  Oblique.  7.  Right  External  Oblique.  8.  Ascending  Colon,  g.  Quadratus 
Lumborum.  10.  Psoas  Muscle.  11.  Inferior  \'ena  Cava.  12.  Cartilage  between  3rd  and  4th 
Lumbar  Vertebra.  13.  Spinous  Process  of  4th  Lumbar  Vertebra.  14.  Lamina  of  3rd  Lumbar 
Vertebra.  15.  Descending  Aorta.  16.  Psoas.  17.  Quadratus  Lumborum.  18.  Descending 
Colon.  19.  External  Oblique.  20.  Internal  Oblique.  21.  Omentum.  22.  Ureter.  23.  Rectus. 
24.  Transverse  Colon. 

it  necessitates  division  of  a  smaller  number  of  nerves  and  vessels 
than  other  methods ;  and  that  it  facilitates  coaptation  by  lying 
in  the  line  of  a  natural  fold,  and  helps  to  prevent  prolapse  of 
the  bowel  by  lying  almost  transversely  to  its  axis.  In  thin 
patients,  and  particularly  in  women,  whose  iliac  crests  are  more 


■i56  COLOTOMY. 

prominent  than  in  men,  there  is  a  tendency  for  the  upper  lip  of 
the  wound  to  fall  inwards,  while  the  lower  lip  protrudes.  This 
may  be  obviated  by  careful  apposition,  and  by  not  bringing  the 
line  of  the  incision  too  close  to  the  ilium. 

The  patient  is  laid  on  his  side,  or  almost  semiprone,  and  a 
hard  round  pillow  is  placed  under  the  opposite  loin,  to  separate 
the  last  rib  from  the  ilium  as  much  as  possible,  and  make  the 
site  of  operation  prominent.  The  centre  is  at  the  point  indicated 
— a  little  behind  the  centre  of  the  crest  of  the  ilium.  Its  length 
will  vary  according  as  the  patient  is  fat  or  thin.  Four  or  five 
inches  is  the  length  usually  recommended ;  but  this  is  the 
extreme.  In  a  thin  patient,  two  inches  is  ample ;  and  I  have 
found,  in  a  very  fat  woman,  three  inches  to  give  plenty  of  room. 
It  will  be  found  most  convenient  to  have  the  bulk  of  the  incision 
behind  the  point  marked  as  the  site  of  the  bowel.  The  incision 
starts  about  an  inch  in  front  of  and  above  this  point,  and  passes 
obliquely  upwards  and  backwards  towards  the  angle  formed  by 
the  spine  and  the  last  rib,  for  a  distance  varying  according  to 
the  nature  of  the  case.  The  various  structures  are  divided  by 
successive  strokes  of  the  knife  or  scissors,  forceps  being  placed 
on  the  bleeding-points.  The  parts  divided  after  the  skin  and 
superficial  fascia  are :  some  fibres  of  the  latissimus  dorsi,  the 
posterior  fibres  of  the  external  oblique,  the  internal  oblique,  and 
the  lumbar  fascia.  The  anterior  edge  of  the  quadratus  lum- 
borum  will  then  appear  in  the  wound,  and  may  be  divided  or 
not,  as  seems  convenient.  The  fibres  of  the  transversalis  may 
often  be  separated  without  division.  When  the  transversalis 
fascia  has  been  divided,  the  fat  which  underlies  the  colon  wil 
bulge  into  the  wound.  Each  of  these  layers  is  divided  to  the 
whole  extent  of  the  cutaneous  incision. 

The  sub-peritoneal  adipose  tissue  is  usually  abundant,  even 
in  lean  subjects.  It  is  frequently  found  in  well-defined  strata, 
separated  by  layers  of  fascia.  I  have  more  than  once  seen  these 
la3ers  mistaken  for  bowel,  and  treated  accordingly.  Indeed, 
when  in  doubt  as  to  a  fascial  fold  being  bowel  or  not,  it  is 
always  best  to  treat  it  as  if  it  were.  An  error  is  then  harmless. 
The  fat  is  teased  aside  by  the  fingers,  a  cutting  instrument  being 


THE   OPERATION.  457 

used  as  sparingly  as  possible.  If  it  is  very  abundant  it  may  be 
removed,  to  give  additional  space. 

Various  means  of  recognising  the  bowel  have  been  described, 
such  as  its  immobility,  and  the  presence  of  bands  on  its  surface. 
These  would  be  valuable  if  the  peritoneum  were  opened.  In 
feeling  for  the  bowel,  the  forefinger  and  thumb,  or  the  first  two 
fingers,  are  inserted  into  the  wound,  separating  its  margins.  The 
bowel,  if  distended,  will  bulge  outwards,  and  may  be  readily 
seized.  If  it  is  empty,  it  is  sought  for  more  deeply  in  the  wound, 
keeping  well  backwards  and  separating  the  overlying  tissues 
widely.  If  the  peritoneum  is  pushed  apart  by  the  two  fingers, 
only  colon  can  be  grasped  between  its  layers.  The  existence  of 
hard  fasces  inside  the  bowel  is  an  infallible  guide.  The  surgeon 
ought,  from  practice  on  the  dead  body,  to  be  familiar  with  the 
sensation  that  colon  gives  when  pinched  up  between  the  fingers 
through  a  lumbar  incision  ;  and  this  sensation  is  more  trust- 
worthy than  any  other  guide,  or  any  combination  of  guides. 

In  a  very  few  cases*  no  colon  has  been  found,  on  account  of 
the  existence  of  congenital  abnormality.  In  others,  the  small 
intestine  has  been  opened  by  mistake  for  the  colon.  We  have 
it  on  the  authority  of  Ballf  of  Dublin  that  one  of  the  most 
experienced  of  living  colotomists  has  candidly  admitted  that  he 
opened  the  duodenum  on  the  right  side,  believing  it  to  be  the 
colon. 

If,  during  the  manipulations,  the  peritoneum  has  been  torn 
through,  it  must  be  closed  at  once.  This  may  be  done  by 
catching  the  edges  of  the  laceration  in  forceps,  pulling  it  into 
the  wound,  and  surrounding  it  with  a  ligature.  This  produces 
perfect  closure,  with  apposition  of  serous  surfaces.  I  have,  on 
one  occasion,  seen  this  done,  and  no  harm  result.  If  the  rent 
in  the  peritoneum  is  large,  the  bowels  may  prolapse  into  the 
wound.  After  reducing  the  bowels,  advantage  may  be  taken  of 
the  presence  of  the  fingers  in  the  cavity  to  search  for  the  colon 
and  make  it  bulge  into  the  wound.  A  forceps  may  then  be 
placed  on  its  wall  as  a  guide,  and  the  rent  in  the  peritoneum 

*  See  Lockwood,  St.  Davt.'s,  IIosp.  Rep.,  vol.  xix. 
t  Tlie  Rectum  and  Anus,  Lond.   1887,  p.   357. 


458 


COLOTOMY. 


closed.     Thereafter  the  operation  is  proceeded  with  as  if  nothin 
had  happened. 

If  the  bowel  is  distended  with  faeces,  the  ends  and  deep  parts 
of  the  parietal  wound  should  be  closed  before  opening  it. 

There  is  always  some  risk  of  burrowing  suppuration  ;  and 
accurate  apposition  of  deep  as  well  as  superficial  parts  ought  to 
be  secured.  The  best  way  to  do  this  is  by  continuous  buried 
sutures  of  catgut  carried  from  the  deep  parts  of  the  wound  to 
its  surface ;  but  deep  silver  button-sutures  answer  fairly  well. 
A  drainage-tube  is  placed  deeply  at  the  end  of  each  half  of  the 
wound.      To  provide  against  the  contact  of  faeces,  the  wound 

must  be  protected  by 
lint  soaked  in  some 
antiseptic  material,  of 
which  there  is  nothing 
better  than  boro- 
glyceride. 

If    there    is    much 

difficulty   in    seizing    an 

un  dilated     colon,     a 

Lund's     insufflator 

(Fig.  56)  may  be   used, 

to   cause   its   distension 

by  air   or   fluid.     Some 

surgeons      recommend 

that    the    operation    be 

begun    by  artificially 

distending     the     colon. 

If    there    is    complete    obstruction    in    the    rectum,   this    is,  of 

course,  impossible;    and,  in  any  case,  it  need  not  be  done  till 

the  necessity  for  it  has  become  apparent. 

The  bowel  may  at  once  be  opened  and  fixed  to  the  edges  of 
the  wound ;  or,  if  there  is  no  urgency,  it  may  be  fixed,  and  the 
opening  delayed  for  a  few  days  till  the  wound  has  united  and 
the  bowel  has  become  adherent  in  its  new  situation.  Delay  in 
opening  the  bowel  greatly  diminishes  the  risk  of  unhealthy 
action  in  the  wound,  and  permits  the  employment  of  antiseptic 


Fig.  56. 

Lund's    Insufflator. 

A.  Hollow  Rubber  Ring  which  is  pressed  against  the 
Tissues  around  the  Anus ;  a.  Rectum  Tube ;  C.  Longer 
Rectum  Tube  ;  B.  Ball-syringe  attached  to  Instrument. 


THE   OPERATION  ''SO 

treatment.  On  the  other  hand,  if  there  is  obstruction,  the  bowel 
musfTe  openecr"aT'Tjnce,^^crn3r  *Wa-««iiind^jarotected  as  well  as 
possible  by  boracic  ointment,  or  carbolised  oil,  or  boro- 
glyceride.  The  experience  of  Davies-Colley  in  the  operation 
a  deux  temps  has  shown  that  symptoms  of  intestinal  strangulation 
may  be  induced  by  the  retention  of  a  loop  of  bowel  in  the 
wound.  To  obviate  this  objection  he  has  devised  a  clamp 
which  holds  the  bowel  between  ivory  studs,  while  it  does  not 
strangulate  it. 

To  fix  the  bowel  in  the  wound,  if  opening  is  to  be  delayed, 
Howse's  plan  of  fixation  by  forceps  is  the  best.  Two  pairs  of 
catch-forceps  are  made  to  grasp  small  folds  of  the  muscular 
coats  of  the  colon  with  just  sufficient  force  to  hold  and  not  to 
cause  sloughing.  They  are  placed  about  half  an  inch  apart, 
and  at  right  angles  to  the  hne  of  incision.  The  forceps  are  laid 
flat  on  the  skin,  and  kept  in  position  by  broad  strips  of  plaster. 
At  the  end  of  a  week,  or  less,  the  bowel  may  be  incised  between 
the  points  where  the  forceps  are  attached.  Sutures  placed  in 
the  bowel  are  liable  to  produce  small  fistulae,  through  which  the 
faeces  escape. 

If  the  bowel  is  to  be  opened  an  once,  it  must  be  fixed  to  the 
edges  of  the  wound  by  sutures.     For  catching  the  bowel  and 

drawing    it    out    of    the 


__^^ 


wound,  Lund--'  has  in- 
vented handled  needles 
with  points  set  at  right 
angles  to  the  shaft,  and 
Pi(,_  ^7^  sharplycurved.  (Fig.  57.) 

Ordinary  curved  needles 
Lund's  Hooks  for  picking  up  the   Bowel  ,,      ^ 

in  Colotomy,  ^o  very  well.    Two  pieces 

of  thick  silk,  with  needles 

at  each  end,  are  inserted  in  the  bowel  at  the  four  corners  of  an 

area    about    an    inch    square.      While   these    stitches,    grasped 

in  the  two  hands  of  an  assistant,  are  made  to  pull  the  bowel 

outwa'rds,  the  surgeon  makes  a  small  opening  with  a  tenotomy 

knife.      A  blunt   hook  passed   through   the  opening  pulls  out 

*  Laneet,  vol.  i.,  188^. 


460 


COLOTOMY. 


the  threads  inside  the  bowel,  which  are  cut  in  the  middle, 
and  thus  make  four  points  of  Qnppor*.  e^^u  ^^<.lxxc  la  mcu 
can  led  through  the  skin  at  the  margins  of  the  wound  by 
the  needle  attached,  and  there  tied.  Around  the  opening 
in  the  bowel  there  will  thus  be  placed  four  sutures  —  two 
on  each  lip  of  the  wound.  Additional  security  will  be 
afforded  by  placing  two  more  stitches,  each  passing  through 
the  edges  of  the  parietal  incision,  and  hooking  up  the  corner  of 
the  opening  in  the  bowel.  I  prefer  silk  to  silver  as  sutures, 
simply  because,  in  the  subsequent  frequent  cleansing  of  the 
wound,  the  ends  of  the  silver  sutures  will  catch  in  the  wool  or 
sponge  and  so  far  interfere  with  the  manipulation. 

In  most  cases  there  is  an  immediate  discharge  of  faeces 
through  the  wound ;  but  sometimes  this  discharge  does  not 
take  place  for  hours,  or  even  for  days.  If  the  fasculent  matter 
is  hard  or  in  lumps,  its  escape  may  be  impossible,  or  it  may 

cause  considerable  pain. 
In  this  event  Lund's  for- 
ceps-'' (Fig.  57)  will  be  found 
useful.  If  the  discharge  is 
frequent  and  abundant,  very 

frequent    dressings    of    the 
LuM'sFovcepsfov  removing  Hardened         ^^^^^^     ^^j^    ^^    necessary. 
ticces  in  Colotomy.  "^ 

Large    pads    of    absorbent 

of  absorbent  antiseptic  and  deodorising  material,  kept  in  position 

by  a  square  of  mackintosh  cloth,  to  each  corner  of  which  a  piece 

of  strapping    has    been    fixed  by  a  safety-pin,  is  a  convenient 

form  of  dressing.     Bandages  carried  round  the  body  are  clumsy 

and  inefficient  as  a  means  of  fixing  the  dressing.     The    piece 

of  adhesive  plaster  at  each  corner  of  the  square  of  mackintosh 

will  be  found  efficient  enough  in  most  cases  ;  if  not,  extra  pieces 

may  be  pinned  on  along  the  borders. 

The  position  of  the  patient  is  not  a  matter  of  great  impor- 
tance. Comfort  will  be  increased  by  changing  the  position 
slightly  at  each   dressing. 

Primary  healing  may  be  anticipated  with  considerable  con- 
*  Lancet,  vol.  i.,  1886. 


Fig.  58. 


THE   OPERATION.  461 

fidence  in  every  case,  provided  the  wound  is  properly  attended 
to.  The  disadvantages  of  suppuration  in  a  wound  constantly 
brought  into  contact  with  faeculent  fluids  and  gases  are  evident 
enough. 

When  the  wound  is  perfectly  healed,  and  the  artificial  anus 
is  established,  an  apparatus  of  some  form  or  other  must  be  worn, 
to  collect  any  faeces  that  may  escape.  Ivory  and  rubber  plugs 
attached  to  an  abdominal  belt  are  made  for  this  purpose.  I 
have  used  a  soft  rubber  bag  attached  to  a  ring  pessary  of  copper 
wire  surrounded  by  wire  tubing,  and  fixed  by  tapes  carried 
round  the  waist.  After  tr3'ing  most  of  the  apparatus  recom- 
mended for  this  purpose,  I  have  come  to  the  conclusion  that 
nothing  is  more  efficient  and  more  comfortable  than  clean  linen 
rags  nicely  folded,  and  kept  in  position  by  a  well-made  linen 
binder.    Patients  themselves  often  devise  ingenious  contrivances. 

Occasionally  faeces  collect  in  the  part  of  the  bowel  below  the 
opening  and  give  trouble.  Bryant  has  seen  symptoms  of  intes- 
tinal obstruction  produced  in  this  way,  in  spite  of  the  presence 
of  the  opening  in  the  bowel.  To  prevent  the  passage  of  faeces 
into  the  lower  segment  of  gut,  various  means  have  been  suggested 
and  adopted.  To  increase  the  acuteness  of  the  flexion  of  the 
bowel,  sutures  have  been  placed  so  as  to  take  in  the  greater  part 
of  the  calibre,  or  even  (although  this  involves  transfixion  of  the 
peritoneum)  the  whole  circle.  Mr,  P.  Jones"  has  succeeded  in 
preventing  the  downward  passage  of  faeces  by  turning  inwards 
and  suturing  the  mucous  membrane  around  the  prolapsing 
portion. 

The  most  thoroughgoing  proceeding  of  this  sort  is  that  of 
Madelung.f  He  recommends  that  the  bowel  be  cut  completely 
through,  that  the  lower  opening  be  closed  and  dropped  inside, 
and  the  upper  opening  be  sutured  to  the  wound  to  form  the 
artificial  anus.  The  irritation  of  faeces  on  the  cancerous  rectum 
is  thus  done  away  with,  and  prolapse  of  the  gut  through  the 
wound  is  less  likely  to  take  place.  There  is  one  risk  attached 
to  Madelung's  proceeding  which  has  not  been  pointed  out ;  and 
that  is  the  accumulation  of  cancerous  discharges  above  the 
*  Brit.  Med.  Journ.,  i836,  i.,  p.  782.      [f  Centralbl.  fiir  Chii'.,  No.  23,  iS8.\. 


462  COLOTOMY. 

stricture,  which,  unable  to  escape  downwards,  would  certainly 
cause  pelvic  cellulitis.  I  have,  in  one  case  on  which  I  had  per- 
formed colotomy,  seen  sudden  stoppage  of  all  discharge  by  the 
anus,  and  appearance  of  it  at  the  artificial  opening.  This  alone 
would  deter  me  from  adopting  Madelung's  suggestion,  even  if 
the  advantages  to  be  secured  were  greater  than  he  claims.  Ball 
of  Dublin  has]  closed  the  divided  lower  segment  of  bowel  after 
laparo-colotomy,  and  dropped  it  inside  the  abdomen,  with  good 
result. 

LAPARO-COLOTOMY. 

Here  the  colon  is  opened  by  an  incision  through  the  parietes, 
in  the  inguinal  region  usuall3\  If  performed  on  the  left  side,  it 
is  Littre's  original  operation.  It  may,  however,  be  performed 
on  either  side — on  the  left,  when  it  is  desired  to  open  the  sig- 
moid flexure ;  on  the  right  side,  when  it  is  desired  to  open  the 
caecum  or  ascending  colon.  The  operation  may  also  be  carried 
out  through  a  median  incision :  in  such  a  case  the  term  "inguinal 
colotom}^"  generally  used  for  the  operation,  is  wrong.  Recent 
experience  has  made  it  necessary  to  review  the  position  which 
extra-peritoneal  colotomy  holds  as  compared  with  intra-peri- 
toneal.  Laparo-colotomy  is  steadily  and  surely  coming  into 
favour,  and  properly  so.  Verneuil,  Ball,*  Allinghani  (junr.),f 
Harrison  Cripps,|  are  among  the  most  conspicuous  support- 
ers of  the  operation,  and  have  introduced  various  important 
modifications  and  improvements. 

Among  the  most  important  advantages  of  laparo-colotomy, 
the  following  may  be  mentioned.  The  large  intestine  can  easily 
be  found,  and  can  scarcely  be  mistaken  for  any  other  portion  of 
bowel.  The  operation  permits  thorough  exploration  and  accu- 
rate diagnosis :  thus,  not  only  may  it  be  possible  to  proceed  to 
a  radical  operation  b}^  excision,  but  there  is  absolute  certainty 
that  the  opening  will  be  made  above  tlie  stricture.  The  opera- 
tion is  a  smaller  affair  altogether  ;  may  be  performed  through  a 
short  abdominal  incision,  and   with    more  expedition  and  less 

*  The  Rectum  and  Anus,  Lond.,  1887,  p.  362. 
t  Brit.  Med.  Jonvn.,  Oct.  22nd,  1887.         \  Brit.  Med.  Joiirn.,  April,  6,  1889. 


LAPARO-COLOTOMY.  463 

shock  to  the  patient.  The  position  of  the  _wound  renders  it 
possible  for  the  patient  to  dress  and  look  after  it.  The  only 
drawback  is  the  necessary  opening  of  the  peritoneum  ;  and  this, 
now-a-days,  is  a  very  small  one.  As  Ball  points  out,  the 
peritoneum  is  opened  in  the  lumbar  operation  by  no  means 
infrequently. 

The  original  operation  was  performed  through  an  incision 
made  parallel  with  Poupart's  ligament,  about  an  inch  above  it, 
starting  at  the  iliac  crest  and  running  inwards  about  two  or 
three  inches.  But  other  lines  of  parietal  incision  may  be  em- 
ployed. Luke  and  Adams  employed  a  vertical  incision  external 
to  the  epigastric  arter}- ,  and  most  other  surgeons  have  their  own 
favourite  sites  of  operating.  As  experience  has  not  yet  settled 
the  best  general  mode  of  operation,  it  will  be  advisable  to 
speciall}^  describe  the  operations  of  Verneuil,  Ball,  AUingham, 
and  Cripps.  Professor  Verneuil,  who  has  for  some  time  advo- 
cated the  inguinal  mode  of  performing  colotomy,  has  introduced 
important  modifications.  To  obviate  the  disadvantage  of 
having  no  spur  or  heel  below  the  artificial  anus  to  prevent  the 
downward  passage  of  faeces,  and  to  provide  against  the  con- 
traction of  the  opening,  are  the  main  purposes  of  his  operation. 
The  incision,  two  inches  in  length,  starts  about  two  inches  to 
the  inside  of  the  iliac  spine,  and  is  directed  upwards  to  the 
umbilicus.  He  catches  the  edges  of  the  abdominal  opening  in 
six  pairs  of  haemostatic  forceps,  to  distend  the  wound  and  pre- 
vent the  peritoneum  from  being  peeled  off".  Enough  intestine 
is  pulled  out  to  make  a  protuberance  as  large  as  a  pigeon's  egg ; 
this  is  transfixed  with  two  acupuncture  needles,  which  lie  on 
the  parietes  and  keep  the  intestine  in  place.  About  fifteen 
metallic  sutures  are  placed  between  intestine  and  abdominal 
wall,  and  the  protruding  piece  of  gut  is  resected.  The  thermo- 
cautery is  used  to  check  bleeding.  The  intestinal  wall,  bulging 
into  the  large  opening,  blocks  the  downward  passsage ;  the 
magnitude  of  the  opening  obviates  the  risk  of  stenosis;  pro- 
trusion is  prevented  by  the  longitudinal  direction  of  the  parietal 
opening,  and  its  comparatively  small  size. 

Ball's  mode  of  operating  may  be  given  in  his  own  words 


464  COLOTOMY. 

"  An  incision  about  four  inches  long  was  made  in  the  left  linea 
semilunaris,  this  position  being  selected  for  the  following 
reasons :  it  freely  exposes  the  sigmoid  flexure ;  it  is  made 
without  cutting  muscle;  the  parietes  are  thinner  here  than 
elsewhere ;  and  no  vessels  of  importance  are  wounded.  The 
deep  epigastric  artery  is  quite  safe  from  injury  if  the  lowest 
limit  of  the  incision  does  not  pass  below  a  line  drawn  from  the 
umbilicus  to  the  middle  of  Poupart's  ligament.  The  upper  limit 
of  the  cancer  having  been  determined,  the  gut  was  emptied 
upwards  by  careful  pressure,  and  a  loop  of  bowel  drawn  out ;  a 
narrow-bladed  clamp  was  now  applied  to  the  intestine,  so  as  to 
prevent  any  faeces  coming  down,  and  a  similar  one  applied  to 
the  distal  extremity  of  the  loop.  In  the  present  case,  Ricord's 
phimosis  forceps,  covered  v/ith  rubber  tubing,  and  closed  b}' 
means  of  elastic  umbrella-rings,  were  used  for  clamps.  (He  has 
since  had  a  clamp  made,  which  has  the  advantage  of  allowing 
the  blades  to  move  quite  parallel.  By  means  of  a  screw  the 
exact  amount  of  pressure  necessary  to  retain  the  loop  of  intes- 
tine in  the  grasp  can  be  applied,  and  bending  at  a  double  angle 
permits  of  the  blade  portion  lying  easily  within  the  peritoneal 
cavity.)  The  clamps  being  applied,  a  number  of  sutures  were 
passed  through  the  abdominal  wall,  including  peritoneum,  on 
one  side,  through  the  intestine  in  front  of  the  damp,  and  through 
the  peritoneum  and  abdominal  wall  on  the  opposite  side. 
Eleven  sutures  were  in  this  way  passed,  five  perforating  each 
portion  of  intestine,  and  one  passing  through  the  meso-colon. 
The  bowel  was  now  opened  between  two  aseptic  sponges,  and 
the  interior  carefully  cleansed  of  mucus  and  faeces.  The  loops  of 
the  sutures  were  hooked  out  from  within  the  lumen  of  the  bowel, 
cut,  and  the  central  ones  tied  on  each  side ;  the  suture  through 
the  meso-colon  was  also  tied  ;  the  sutures  through  the  angles  of 
the  abdominal  wound  and  outer  borders  of  the  bowel  alone 
remaining  unclosed.  A  number  of  superficial  sutures  were  now 
put  in,  so  as  to  render  the  application  of  the  mucous  membrane 
to  the  skin  extremely  accurate  all  round,  except  at  the  angles 
where  the  handles  of  the  clamps  lay.  The  clamps  were  now 
withdrawn  one  by   one,   and  the   remaining   sutures  at  either 


ALLINGHAM'S  OPERATION.  465 

angle  simultaneously  closed,  thus  shutting  off  the  opening  into 
the  peritoneal  cavity  at  the  moment  that  the  clamps  released  the 
bowel.  The  single  suture  through  the  meso-colon  is,  I  think,  of 
use  in  ensuring  a  larger  surface  of  peritoneum  being  in  appo- 
sition to  the  abdominal  wound,  and  the  second  clamp  on  the 
distal  extremity  of  the  bowel,  although  not  as  essential  as  the 
other,  facilitates  the  operation  considerably." 

In  Allingham's  operation  the  bowel  is  kept  forward  in  the 
wound  by  a  suture  passed  behind  the  gut  and  through  the  mesen- 
tery, and  fixed  in  the  edges  of  the  parietal  wound.  He  makes  the 
parietal  incision,  two  inches  in  length,  about  one  inch  inside  the 
anterior  superior  spine  of  the  ilium,  and  parallel  with  Poupart's 
ligament.  The  divided  peritoneal  margins  he  at  once  sutures 
to  the  skin.  The  sigmoid  flexure  is  then  searched  for  with  the 
fingers,  and  the  intestine  pulled  to  the  surface.  A  piece  with 
long  mesentery  is  then  fixed  upon,  and  "  a  needle  threaded  with 
carbolised  silk  is  passed  through  the  mesentery,  close  to  the 
intestine  on  both  sides,  then  through  the  abdominal  wall  on  both 
sides,  nearer  to  the  lower  than  the  upper  angle  of  the  wound, 
and  these  are  tied  tight."  The  bowel  is,  in  fact,  hung  up  over 
the  silk  thread.  The  protruding  bowel  is  then  carefully  sutured 
to  the  parietal  opening  all  round.  Antiseptic  dressings  are 
applied,  and  the  wound  is  not  disturbed  for  a  few  days. 

At  the  end  of  two  or  three  days  the  dressings  are  removed, 
the  whole  exposed  bowel  being  found  covered  with  lymph,  and 
the  opening  made.  To  open  the  gut  he  uses  scissors,  "  cutting 
the  intestine  from  above  downwards  to  the  extent  of  about  an 
inch  and  a  half ;  through  the  incision  can  be  seen  two  orifices 
separated  by  a  well-formed  spur,  the  upper  opening  being  the 
larger,  the  lower  the  smaller,"  on  account  of  the  supporting 
thread  being  placed  nearer  to  the  lower  than  the  upper  end  of  the 
wound.  The  superfluous  gut  by  the  edges  of  the  wound  ma}^  be 
cut  away.  Such  operations  on  the  gut  are  quite  painless,  and 
require  no  anaesthetic. 

Allingham's  method  of  operating  is  clearly  a  valuable  one. 
He  supports  its  recommendation  by  records  of  six  very  suc- 
cessful operations.     I  would  suggest  that  the  supporting  thread 

31 


466  .  COLOTOMY. 

passed  under  the  gut  should  not  be  tied  close  to  the  edge  of  the 
wound,  but  should  be  carried  through  the  parietes  under  the 
skin  for  a  distance  of  two  or  three  inches,  and  the  ends  fixed  in 
buttons.  The  risk  of  contamination  of  peritoneum  through  the 
suture-holes  would  thereby  be  done  away  with.  He  does  not 
recommend  it  for  cases  in  which  immediate  opening  of  the  gut 
is  necessary.  As  regards  the  mere  opening  of  the  gut,  I  think 
he  unnecessarily  restricts  its  applicability ;  but  in  cases  where 
the  bowel  is  greatty  distended  with  faeces,  and  there  would  be 
difficulty  or  danger  in  placing  the  thread  under  it,  then  his 
restriction  should  be  enforced.  For  enterotomy  the  proceeding 
seems  equally  well  adapted.  The  chief  drawback  to  Allingham's 
mode  of  operating  would  seem  to  be  the  tendency  of  the  bowel 
to  prolapse,  which  is  sometimes  very  great.  To  obviate  this 
tendency  he  recommends  the  removal  of  all  superfluous  bov/el 
with  its  mesentery  after  it  has  been  pulled  out  into  the  wound 
as  far  as  possible.  As  much  as  seven  inches  of  gut  have  thus 
been  removed.  This  seems  to  be  a  somewhat  severe  proceed- 
ing, and  v.'ill  prove  detrimental  to  the  favourable  acceptance 
which  his  mode  of  operating  seemed  likely  to  receive.* 

The  operation  as  performed  by  Harrison  Cripps  may  also 
be  given  in  his  own  words.  "  The  patient  has  a  warm  bath  the 
night  previous  to  the  operation,  the  abdomen  being  thoroughly 
cleansed  with  soap  and  water,  and  afterwards  covered  with  a 
light  antiseptic  dressing.  This  is  important ;  for,  since  the 
operation  is  usually  undertaken  for  cancer  of  the  rectum,  the 
part  is  liable  to  become  contaminated  with  the  fetid  dis- 
charge. I  make  my  incision  higher  than  most  operators.  The 
branches  of  the  epigastric  artery  are  thus  avoided,  and  there  is 
subsequently  less  pressure  on  the  wound  than  when  lower  down. 
As  a  guide  I  take  an  imaginary  line  from  the  anterior  superior 
spine  to  the  umbilicus ;  the  incision,  two  inches  and  a  half  long, 
crosses  this  at  right  angles,  an  inch  and  a  half  from  the 
superior  spine.  Half  the  cut  is  above,  and  half  below  the 
imaginary  line.  ...  In  making  the  incision  the  skin  should 
be  drawn  a  little  inwards,  so  as  to  make  the  opening  somewhat 
*  See  Bvit,  Med.  Journ.,  April  27th,  1889. 


CRIPPS'   OPERATION.  467 

valvular.  The  peritoneum  being  reached,  it  is  pinched  up  by 
fine  forceps  and  an  opening  made  sufficient  to  admit  the  finger. 
The  intestines  being  protected  by  the  finger,  the  peritoneum  is 
divided  by  scissors  to  nearly  the  full  length  of  the  cutaneous 
incision.  The  colon  may  now  at  once  show  itself,  and  can 
easily  be  recognised  by  its  longitudinal  bands,  its  glandulas 
epiploicae,  and  by  its  regular  convoluted  surface. 
Sometimes  it  can  be  detected  by  the  hard  scybalous  masses 
within  it,  or  it  can  be  traced  up  after  passing  the  finger  into  the 
pelvis  and  feeling  for  it  as  it  crosses  the  brim. 

"  The  colon  being  found,  a  loop  of  it  is  drawn  into  the  wound. 
In  order  to  avoid  the  prolapse  which  is  likely  to  occur  if  loose 
folds  of  the  sigmoid  flexure  remain  immediately  above  the  open- 
ing, I  gently  draw  out  as  much  loose  bowel  as  will  readily  come, 
passing  it  in  again  at  the  lower  angle  as  it  is  drawn  out  from 
above.  In  this  way,  after  passing  through  one's  fingers,  an 
amount  varying  from  one  to  several  inches,  no  more  will  come. 
Two  provisional  ligatures  of  stout  silk  are  passed  through  the 
longitudinal  muscular  band  opposite  to  the  mesenteric  attach- 
ment. These  provisional  ligatures,  the  ends  of  which  are  left 
long,  help  to  steady  the  bowel  during  its  subsequent  stitching  to 
the  skin,  and,  moreover,  are  useful  as  guides  when  the  bowel  is 
ultimately  opened.     They  should  be  about  two  inches  apart. 

"  The  bowel  is  now  temporarily  returned  into  the  cavity. 
With  a  pair  of  fine  forceps  the  parietal  peritoneum  is  picked  up 
and  attached  to  the  skin  on  each  side  of  the  incision,  the 
muscular  coats  of  the  abdominal  wall  not  being  included.  Four 
sutures  of  fine  Chinese  silk  are  sufficient :  two  on  each  side,  an 
inch  and  a  half  apart. 

"  The  bowel  is  again  drawn  out,  and  fixed  to  the  skin  and 
parietal  peritoneum  by  seven  or  eight  fine  ligatures  on  each 
side,  the  last  suture  at  each  angle  going  across  from  one  side 
to  the  other.  The  bowel  should  be  so  attached  as  to  have  two- 
thirds  of  its  circumference  external  to  the  sutures.  By  turning 
the  bowel  slightly  over  the  lower  longitudinal  band  can  be 
clearly  seen ;  and  it  is  best  to  pass  the  sutures  for  the  lower  side 
through  this,  since  it  is  a  strong  portion  of  the  gut.     The  upper 

31  * 


468  COLOTOMY 

longitudinal  band,  through  which  the  provisional  ligatures  have 
already  been  passed,  is  seen  in  the  middle  line  of  the  wound. 
The  bowel  being  now  turned  downwards,  the  opposite  line  of 
sutures  are  inserted  close  to  its  mesenteric  attachment.  The 
sutures,  of  the  finest  Chinese  silk,  are  passed  by  small,  partly- 
curved  needles,  the  needle  passing  through  the  skin  one-eighth 
of  an  inch  from  the  margin,  then  through  the  parietal  layer  of 
peritoneum,  and,  lastly,  partly  through  the  muscular  coat  of  the 
bowel,  great  care  being  taken  to  avoid  perforating  the  mucous 
membrane.  It  is  easier  to  pass  all  the  threads  before  tying 
them  up." 

The  wound  is  cleansed  thoroughly  and  the  bowel  is  either 
opened  at  once  if  the  case  is  urgent  or  covered  up  and  opened 
after  a  few  da3-s.  It  is  necessary  to  place  a  bandage  or  strapping 
firmly  over  the  wound  to  prevent  protrusion  in  the  case  of 
sickness. 

The  bowel  is  opened  without  an  anaesthetic  for  the  whole 
length  between  the  provisional  ligatures,  and  the  superfluous  flaps 
trimmed  off  to  the  level  of  the  skin. 

In  this  way  a  satisfactory  artificial  anus  is  usually  formed. 
Occasionally  the  opening  contracts  too  much,  forming  a  fistula 
which  permits  dribbling  of  intestinal  contents  :  to  prevent  con- 
tractions, Cripps  uses  a  special  spring  dilator.  Prolapse  of  the 
bowel  after  this  mode  of  operating  would  not  seem  to  be  a 
frequent  result ;  and  when  it  occurs,  it  is  said  to  be  easily  con- 
trolled by  a  compress  and  bandage. 

My  experience  of  enterotomy  and  colotomy  by  abdominal 
section  leads  me  to  believe  that  certain  modifications  in  the 
operations  described  may  be  advisable.  I  have  never  fully 
appreciated  the  so-called  advantages  of  the  inguinal  incision  ; 
and  I  should,  unless  there  were  contra-indications,  prefer  to 
operate  through  the  linea  alba,  and  make  the  artificial  anus 
there.  There  is  practically  always  sufficient  length  of  bowel 
and  mesenter}^  to  reach  the  middle  line :  the  experience  of 
operators  would  seem  to  prove  that  for  the  inguinal  route  there 
is  too  much  length  of  mesentery  and  bowel ;  Allingham,  indeed, 
gives  this  as  the  chief  or  only  cause  of  prolapse.     Also  bringing 


MODIFICATIONS.  469 

the  bowel  to  the  middle  line  causes  a  more  acute  flexure  of  its 
calibre  than  bringing  it  out  at  the  inguinal  opening ;  and  this 
acute  flexure  is  one  of  the  most  efficient  ways  of  forming  a  spur. 
In  lumbar  colotomy,  as  a  rule,  there  is  a  more  acute  flexure  and 
more  traction  than  in  inguinal  colotomy ;  and  here  there  is, 
probably,  less  tendency  to  prolapse. 

I  do  not  consider  it  advisable  to  stitch  the  parietal  peri- 
toneum to  the  skin,  but  prefer  to  leave  the  bowel  free  in  the 
incised  opening.  Although  the  union  of  skin  and  peritoneum 
insures  the  apposition  of  serous  surfaces  and  rapid  agglutination 
between  bowel  and  peritoneum,  it  does  not  secure  a  strong 
permanent  fixation.  The  subperitoneal  fat  glides  easily,  after 
a  week  or  so,  over  the  parietal  incision,  and  the  adherent 
bowel  falls  back  with  it,  as  is  often  seen  and  described  in  this 
mode  of  operating.  The  peritoneum  joins  to  the  bare  incised 
margins  quite  quickly  enough  ;  its  junction  is  over  a  broader 
surface,  and  it  is  more  firm  and  more  permanent.  The  muscles 
surrounding  the  bowel  take  a  direct  grip  of  it,  and  there  is  no 
intervening  subserous  layer  to  permit  slipping  or  gliding  away 
from  its  grasp.  A  direct  implantation  of  the  bowel  by  a  broad 
surface  on  muscle,  fat,  and  fascia  is  not  so  likely  to  lead  to 
prolapse  as  an  indirect  and  comparatively  loose  attachment 
through  lax  subperitoneal  areolar  tissue. 

I  believe,  therefore,  that  experience  will  show  that  the  best 
mode  of  performing  peritoneal  colotomy  will  be  by  a  median  in- 
cision below  the  umbilicus  ;  that  direct  implantation  of  the  bowel 
on  the  raw  incision  will  be  found  most  effectual  in  securing  per- 
manent adhesion,  and  that  the  use  of  the  supporting  loop  of 
thread  as  practised  by  Allingham  will  be  found  of  value  in  many 
cases.  In  the  actual  operation  every  experienced  surgeon  will 
adopt  modifications  of,  and  departures  from,  any  set  method. 


Resection  of  Intestine. 
Entereetomy;   Colectomy;  Csecectomy. 

Removal  of  a  piece  of  small  intestine  is  known  as  enteree- 
tomy ;  the  same  operation  applied  to  the  large  intestine  is 
called  colectomy.  Caecectomy,  or  excision  of  the  caecum, 
usually  involves  the  removal  of  part  of  the  ileum  and  part  of 
the  ascending  colon  as  well.  The  operations  may  be  considered 
conjointly. 

Histoiy. — It  would  seem  that  this  is  by  no  means  a  novel 
proceeding.  According  to  Dr.  E.  J.  111,"-^'-  Randohr,  in  1727, 
successfully  removed  two  feet  of  gangrenous  intestine  from  a 
hernia.  Up  to  1836,  the  same  writer  tells  us  the  operation  had 
been  performed  at  least  ten  times  by  French,  German,  and 
English  surgeons.  Of  these  cases,  5  were  cured,  2  were  left 
with  artificial  anus,  and  3  died.  Such  operations,  however, 
were  rather  timorous  removals  of  sloughs,  than  deliberate 
resections  of  bowel.  Such  a  case  is  one  where  Mr.  Cookesle}-,! 
a  surgeon  of  Crediton,  in  1731,  removed  six  inches  of  gangrenous 
bowel  in  a  case  of  strangulated  hernia,  and  the  patient  com- 
pletely recovered.]: 

*  Neiu  York  Med.  Rec,  Sept.  22nd,  1883. 
t  Med.  Essays  and  Observations,  Edinburgh,  1752,  p.  357. 

\  The  following  interesting  record  is  from  Cheselden's  Anatomy,  p.  151. 
Lond.,  1730 : — 

"  Thomas  Brayn  of  Yeaton,  in  the  parish  of  Baschurch,  and  county  of 
Salop,  a  doctor  for  cattle,  maketh  oath,  that  about  ten  or  twelve  years  agone, 
he  was  sent  for  by  a  farmer  or  husbandman,  who  lived  near  the  village  called 
Maesbrooks,  and  very  near  to  the  river  Verney,  in  the  said  county  of  Salop, 
to  have  his  advice  about  an  ox  he  had,  which  was  then  sick  by  reason  he 
could  not  dung ;  he  had  been  drenched  by  several  beast  doctors  before  this 
deponent  came  to  him.  This  deponent  seeing  this  ox  in  the  condition  he  was 
in,  told  the  owner,  that  if  he  would  venture  his  ox,  he  would  do  him  what 
service  he  could,  in  the  curing  of  him ;  which  the  owner  consented  to,  and 
thereupon  this  deponent  opened  the  ox  in  the  flank,  and  took  great  part  of  his 
bowels,  upon  searching  which  he  found  there  was  a  perfect  stoppage  in  the 
guts ;  and  the  gut  was  about  the  stoppage  putrified  for  about  three-quarters 


HISTORY.  471 

The  removal  of  a  diseased  portion  of  colon  was  first  sugges- 
ted by  Littre,  in  1710;  but  it  was  not  till  1833  that  the  first 
operation  was  performed.  According  to  Marshall,"  Reybard  of 
Lyons,  who  made  claim  to  having  performed  the  first  colectomy, 
presented  his  paper  to  the  French  Academy  of  Medicine  in  1844; 
but  it  was  rejected  for  publication  in  the  Memoirs  of  that  body, 
on  account  of  some  want  of  definiteness  in  the  record.  It  seems 
almost  certain,  however,  that  he  did  excise  a  tumour  from  the 
sigmoid  flexure,  along  with  some  portion  of  bowel ;  that  he 
sutured  and  returned  the  divided  gut ;  and  that  the  patient  lived 
for  ten  months  afterwards,  passing  faeces  per  anum.  The  next 
operation  is  credited  to  Gussenbauer  of  Liege  in  1877.  In  his 
case,  a  primary  median  incision  was  supplemented  by  a  trans- 
verse one:  his  patient  died  in  15  hours.  In  1879  he  attempted 
another  operation,  but  had  to  finish  it  as  a  lumbar  colotomy. 
In  1878  Baum  of  Dantzic  supplemented  a  vertical  incision  for 
enterectomy  by  a  transverse  one,  and  removed  a  growth  in  the 
ascending  colon,  with  some  inches  of  bowel  above  and  below. 
Faeces  escaped  through  the  wound,  and  the  patient  died  on  the 
seventh  day.  In  1879  Martin  of  Hamburg  had  a  brilliant 
success  after  a  most  difficult  operation,  in  which  he  removed  a 
large  growth  with  a  portion  of  the  sigmoid  flexure  and  some 
glands.  In  1880  Czerny  had  a  partial  success  after  a  difficult 
operation,  the  patient  dying  seven  months  afterwards  from  a 
recurrence  of  the  disease.  In  1881  Bryant  finished  a  lumbar 
colotomy  by  removing  the  diseased  bowel ;  and  in  1882  Marshall 
unsuccessfully  removed  a  growth  from  the  descending  colon  by 

of  a  yard,  whereupon  this  deponent  cut  off  so  much  of  the  gut  as  was 
putrified,  and  took  it  quite  away,  and  then  drew  the  ends  of  the  guts  which 
remained  sound  after  what  was  cut  off,  together  upon  a  hollow  keck,  which 
was  about  three  or  four  inches  long,  and  sewed  the  said  ends  of  the  guts 
together  upon  the  said  keck,  leaving  the  keck  within  the  guts,  and  then 
sewed  up  the  hole  cut  in  the  hide  upon  the  flank  of  the  said  ox ;  and 
this  deponent  further  saith,  that  within  the  space  of  one  hour  after  this 
operation  was  performed,  the  ox  dunged ;  and  the  piece  of  the  keck  which 
the  said  ends  of  the  guts  were  sewn  upon  and  left  within  the  guts,  came 
away  from  the  ox  with  the  dung,  whereupon  the  ox  recovered,  and  lived 
to  do  the  owner  service  several  years." 

*  Lancet,  May  13th,  1882. 


472  RESECTION   OF  INTESTINE. 

lumbar  incision,  after  having  failed  by  median  section.  Since 
then  a  number  of  cases  have  been  recorded. 

Whitehead  of  Manchester*  has  resected  the  caecum  through 
an  incision  made  along  the  side  of  the  rectus  muscle.  The 
ileum  was  stitched  to  the  lower  part  of  the  wound  and  the 
colon  to  the  upper  part,  an  artificial  anus  being  left.  The 
patient  died. 

Resection  of  the  intestine  did  not,  however,  assume  the 
position  of  a  recognised  operation  till  1875,  when  Langenbeck 
revived  it,  to  be  followed  in  1877  by  Kiister.  Since  then  the 
proceeding  has  made  rapid  strides  in  public  estimation,  and  is 
now  regarded  as  one  of  the  most  successful  of  heroic  operations. 

Conditions  for  which  Resection  of  Intestine  may  he  Performed.  Indi- 
cations and  Contva-indications. — Resection  of  bowel  is  usually  called 
for  in  one  or  other  of  three  distinct  conditions  ;  namely,  gangrene, 
stricture,  and  artificial  anus. 

Gangrene  is  usually  associated  with  some  form  of  ob- 
struction of  the  bowels.  In  this  case  resection  is  most  often 
a  necessary  termination  to  an  operation  designed  merely  to 
relieve  obstruction.  It  may  require  to  be  carried  out  at 
any  of  the  ordinary  sites  of  hernia,  or  through  an  abdominal 
incision. 

McCoshf  has  collected  and  tabulated  115  cases  of  resection 
of  gangrenous  strangulated  intestine  where  immediate  suture 
was  carried  out.  Of  these  one  half  recovered.  Resection  with- 
out suture  and  simply  followed  by  fixation  of  the  divided  ends  in 
the  wound  so  as  to  form  artificial  anus,  will  frequently  be  the 
better  operation  to  perform.  Great  weakness  of  the  patient, 
and  consequent  inability  to  bear  a  long  operation,  and  the  ab- 
sence of  a  line  of  demarcation,  would  be  the  chief  reasons  for 
making  artificial  anus.  On  the  other  hand,  resection  with 
enterorraphy  would  be  preferred  if  the  patient's  condition  were 
fairly  good,  and  if  the  gangrene  were  so  high  up  in  the  small 
bowel  that  the  patient  would  suffer  from  starvation  if  an  artificial 
anus  were  left. 
*  Brit.  Med.  Jouyn.,  Jan,  24th,  18S5.       f  N.Y.  Med.  Joimi.,  Mar.  16,  1S89. 


INDICATIONS  FOR   OPERATION.  473 

In  cases  of  stricture,  simple  or  malignant,  resection  is  prac- 
tically the  only  means  of  cure.  The  formation  of  an  artificial 
anus  above  the  stricture  is  only  a  palliative  measure,  intended 
to  tide  the  patient  over  danger  of  death  from  obstruction. 
Cancerous  stricture  is  found  almost  uniformly  in  the  large  intes- 
tine. Of  35  cases  of  resection  of  cancerous  bowel  tabulated  by 
Weir,"  all  save  one  involved  the  large  bowel.  Butlin.t  after  a 
critical  examination  of  Weir's  cases,  eliminates  two  in  which  the 
operation  was  incomplete.  To  the  33  remaining  he  has  added 
4  :  of  this  total  of  37,  32  were  of  the  large  intestine,  3  of  the 
small  intestine,  and  2  uncertain.  The  parts  of  large  intestine 
involved  were:  caecum,  7;  ascending  colon,  4;  transverse 
colon,  3;  descending  colon,  7;  sigmoid  flexure,  g;  "colon,"  2. 
Simple  stricture  is  most  common  in  the  small  bowel. 

It  may  occasionally  happen  that,  in  cases  of  obstruction 
produced  by  peritoneal  adhesions,  it  is  impossible  to  disentangle 
the  coils.  In  such  cases  the  choice  lies  between  enterotomy  as 
a  palliative  measure,  and  resection  as  a  means  of  care.  The 
decision  will  be  guided  by  the  condition  of  the  patient,  and 
the  length  of  intestine  involved.  Koeberlej  on  one  occasion 
did  not  hesitate  to  resect  more  than  six  feet  of  small  bowel 
entangled  in  adhesions. 

In  cases  of  intestinal  fistulae  where  all  minor  modes  of  treat- 
ment have  failed,  and  where  the  patient  is  steadily  losing 
ground,  resection  may  be  called  for. 

In  small  irreducible  intussusceptions,  resection  may  be  the 
best  plan  of  treatment.  Here  the  formation  of  an  artificial 
anus,  though  it  removes  the  dangers  of  obstruction,  leaves 
untouched  the  equally  dangerous  condition  of  intussusception. 
Both  risks  are  avoided  by  resection. 

Removal  of  portions  of  bowel  may  be  called  for  in  cases  of 
perforating  ulcer  arising  from  constriction  by  bands,  or  the 
presence  of  a  foreign  body,  or  in  examples  of  multiple  or 
lacerated  wound  which  cannot  be  perfectly  sutured. 

The   operation   is   contra -indicated   according   to   ordinary 

*  Nezv  York  Med.  Journ.,  Feb.  13th,  1886,      t  Opcr.  Surg,  of  Malig.  Dis.,  p.  231. 
I  Mem.  de  la  Soc.  de  Chir.  dc  Paris,  1881,  p.  99. 


474  RESECTION   OF  INTESTINE. 

surgical  rules.  Where  the  strength  of  the  patient  is  so  under- 
mined that  a  prolonged  operation  would  be  likely  to  cause  death, 
no  operation  is  to  be  thought  of.  In  malignant  disease,  symp- 
toms of  obstruction  are  considered  by  Schede  to  contra-indicate 
resection.  I  should  be  inclined  rather  to  say  that  it  contra- 
indicates  intestinal  suture,  or,  in  more  general  terms,  a  greatl}^ 
prolonged  operation.  The  disease  may  be  very  quickly  removed 
and  the  divided  ends  of  bowel  fixed  in  the  wound,  almost  as 
speedily  as  the  simple  intestinal  opening.  Unfortunately,  too 
many  of  the  cases  are  complicated  by  symptoms  of  obstruction. 
In  every  case  a  minute  examination  of  the  parts  should  be  made, 
to  make  certain  that  the  whole  of  the  disease  can  be  removed. 

Mortality  and  Appreciation. — The  most  complete  statistics  of 
enterectomy  have  been  furnished  by  Reichel.*-'  Of  121  cases 
of  resection  of  the  bowel,  with  suturing  of  the  divided  ends, 
58  died  and  58  were  cured,  and  5  recovered  with  faecal  fistula. 
Ill  collected  47  cases,  with  25  deaths.  The  most  frequent  cause 
of  death  is  peritonitis,  started  by  some  defect  in  the  operation  ; 
more  than  one-half  of  the  deaths  are  so  caused.  The  best 
results  are  got  after  the  operation  for  artificial  anus.  From 
the  elaborate  tables  of  Makins,!  which  give  many  valuable 
facts  for  which  I  have  not  here  space,  we  gather  that  of  39 
cases  of  resection  for  artificial  anus  15  died,  3  were  left  uncured, 
and  the  rest — 21 — were  cured.  Weir's  statistics  of  33  com- 
pleted resections  of  cancerous  intestine  give  a  mortality  of 
51.5  per  cent.  Mr.  Kendal  Franks  ;|:  has  collected  51  cases  of 
colectomy  for  cancer,  with  a  mortality  of  40.8  per  cent. 

There  would  seem  to  be  no  doubt  that,  in  cases  of  obstruction 

at  least,  the  best  results  are  got  after  the  formation  of  artificial 

anus.     This  is  as  might  be  expected.     But  it  is  doubtful  if  the 

double  mortality  from  the  double  operation  would  be  much  less 

than  the  simple  mortality  from  the  single  operation.     If  the 

artificial  anus  is  cured  by  measures  short  of  resection,  which 

can  usually  be  done  by  methods  to  be  described  presently,  then 

the  mortalit}'  would  be  much  smaller. 

*  Deutsche  Zeitschrift  filv  Chirurgie,  1883,  p.  230. 

t  St.  Thomas's  Hosp.  Rep.,  vol.  xiii.,  1884,  p.  81. 

\  Brit.  Med.  Journ.,  March  2,  1889. 


THE   OPERATION.  475 


THE    OPERATION. 

Special  names  are  given  to  the  operation,  as  one  or  other 
part  of  bowel  is  involved.  Colectomy  means  removal  of  por- 
tions of  the  colon  ;  csecectomy  usually  involves,  not  only  removal 
of  the  caecum,  but  parts  of  the  ileum  and  colon  as  well ;  enter- 
ectomy,  the  best  known  term,  is  usually  applied  indiscriminately 
to  any  part  of  bowel,  but  it  will  be  convenient  to  limit  its 
meaning  to  resection  of  the  small  bowel. 

In  its  main  features,  the  operation  is  the  same,  whatever  part 
of  the  bowel  is  involved,  wherever  the  opening  may  be,  and 
whatever  the  disease.  Special  descriptions  will  be  given  where 
it  is  necessary  to  specify  departures  from  the  routine  method. 

The  proceeding  may  be  described  in  three  stages :  (i)  Isola- 
tion of  the  bowel,  (2)  Resection,  and  (3)  Suturing  of  the  divided 
ends,  or  Enterorraph}'. 

Isolation  of  the  Portion  to  be  Resected. — In  every  case  it  is  neces- 
sary to  make  a  full  and  particular  examination  of  the  diseased 
part  before  proceeding  to  remove  it. 

In  the  case  of  gangrenous  bow'el  protruding  through  a  hernia, 
gentle  traction  is  emplo3'ed  to  bring  healthy  bowel  into  view, 
and  to  make  certain  that  the  healthy  portion  can  be  brought  far 
enough  outside  to  permit  of  its  being  resected  and  sutured.  If 
simple  traction  will  not  suffice,  on  account  of  the  smallness  of 
the  opening,  or  the  presence  of  adhesions,  or  great  distension 
of  the  abdominal  portion  of  gut,  then  the  simple  herniotomy 
must  be  enlarged  into  abdominal  section. 

When  the  gangrenous  bowel  lies  inside  the  abdominal  cavit}', 
we  must  carefully  examine,  and  see  that  the  healthy  bowel 
beyond  the  gangrene  is  free  and  sufficiently  movable  to  be 
brought  to  the  surface.  I  have  found  a  gangrenous  portion 
of  bowel  under  a  peritoneal  band  so  firmly  adherent  in  the 
neighbourhood  of  the  pancreas  that  resection  was  impossible. 

In  the  case  of  malignant  disease,  not  only  are  the  upward 
and  downward  limits  to  be  accuratel}'  noted,  but  the  mesenteric 
folds  in  the  neighbourhood  must  be  explored  to  make  sure  that 


476 


RESECTION   OF  INTESTINE. 


the  glands  are  healthy.  One  or  two  glands  in  the  area  of 
mesentery  attached  to  the  bowel  may  be  removed,  and  this  need 
not  contra-indicate  operation  ;  but  if  glands  are  infected  beyond 
this  area,  the  operation  must  be  abandoned.  Adhesions  to 
neighbouring  bowel  ought,  in  my  opinion,  to  contra-indicate 
resection. 

In  artificial  anus,  the  mode  of  isolating  the  bowel  is  some- 
what peculiar;  and  this,  coupled  with  other  peculiarities,  will 
render  necessary  a  special  description. 

The  lines  of  resection  being  fixed  upon,  the  portion  of  bowel 
to  be  removed  is  isolated  as  perfectly  as  possible  from  the 
general  peritoneal  cavity.  Soft  sponges,  of  suitable  size  and 
shape,  are  packed  all  round  the  abdominal  opening,  for  the 
double  purpose  of  preventing  unnecessary  exposure  of  bowel, 
and  excluding  foreign  matter  which  might 
escape  from  the  divided  intestine. 


Resection  of  the  Diseased  Bowel, —  I  have 
already  insisted  on  the  importance  of  never 
closing  an  abdominal  incision  over  distended 
bowels.  If  the  case  is  one  of  obstruction, 
there  will,  of  course,  be  accumulation  of  in- 
testinal contents  above  the  seat  of  obstruc- 
tion ;  and  in  many  cases  of  malignant  disease 
there  is  an  accumulation  of  faeces,  though 
there  is  no  obstruction  in  the  proper  sense 
of  the  word.  In  either  case  I  should  en- 
deavour, as  part  of  the  proceeding  of  resec- 
tion, to  empty  the  bowel  above  as  thoroughly 
as  possible. 

This  may  be  done  easily  enough  in  the 
case  of  gangrene.  Two  Makins'  forceps- 
clamps  (Fig.  59)  are  placed,  one  on  each  side 
of  the  site  of  resection,  at  the  lower  limit 
of  the  disease.  The  bowel  is  divided  between 
them,  and  before  doing  anything  else  the 
lower  portion  of  divided  bowel  is  carefully 


Fig.  59. 

Makins'  Clamp  jor 

Resection 

of  Intestine. 


CLAMPS.  477 

cleansed.  Then  the  gangrenous  bowel  is  rapidly  divided  by- 
scissors  from  its  mesentery  for  the  whole  distance  contemplated, 
catch-forceps  being  placed  on  bleeding  points.  The  gangrenous 
tube  thus  set  free  is  used  as  a  conduit  to  carr}^  the  faeces  as  far 
as  possible  away  from  the  abdominal  wound  into  a  suitable 
receptacle.  The  escape  of  fluids  may  be  encouraged  by  knead- 
ing the  abdomen.  When  the  flow  ceases,  a  clamp  is  placed 
above  the  line  of  the  upper  incision,  and  the  gangrenous  bowel  is 
removed  by  scissors. 

If  the  disease  is  stricture,  it  will  not  be  possible  to  make  use 
of  the  partly  resected  tube  to  convey  the  faeces  away  from  the 
abdominal  opening.  Nevertheless,  if  there  is  much  distension, 
I  should  make  an  effort  to  relieve  it  through  the  incised  upper 
end  of  bowel.  This  may  be  safely  done  after  careful  packing 
with  antiseptic  cloths. 

In  the  preceding  description  the  gut  is  said  to  be  closed, 
above  and  below  the  lines  of  resection,  by  clamps.  There  are 
several  intestinal  clamps,  those  of  Treves*  and  Bishop f  being 
best  known.  Dr.  Abbe  of  New  York  has  invented  an  excellent 
clamp  in  which  the  blades  are  covered  by  flannel,  as  being  less 
likely  to  slip  than  rubber,  and  in  which  compression  is  main- 
tained by  elastic.  Objection  has  been  taken  to  these  instru- 
ments that  they  are  cumbersome,  interfering  with  facility  of 
manipulation  and  suturing,  and  that  their  unyielding  compres- 
sion is  likely  to  be  injurious  to  the  intestinal  walls.  Many 
surgeons  content  themselves  with  the  soft  dexterous  fingers 
of  an  assistant ;  and  if  these  can  be  trusted,  nothing  is  better. 
The  nearest  approach  to  the  fingers  is  the  simple  spring  forceps- 
clamp  recommended  and  used  by  MakinsJ  (Fig.  59),  and  found 
perfectly  efficient.  It  is  made  on  the  principle  of  Dieffenbach's 
spring  catch-forceps,  with  the  addition  of  a  screw,  and  has 
blades  long  enough  to  compress  the  whole  width  of  the  bowel, 
while  it  may  be  applied  without  perforating  the  mesentery. 
The  blades  are  covered  with  rubber  tubing,  to  minimise  the 
risk  of  injury  to  the  intestinal  coats.     Four  clamps  are  used, 

*  Med.-Chir.  Trans.,  vol.  Ixvi.,  p.  5j.  t  Brit.  Med.  Journ.,  Nov.  3rd,  1883. 

+  St.  Thomas's  Hosp.  Rep.,  1884,  p.  81. 


478  RESECTION   OF  INTESTINE. 

one  being  placed  on  each  side  of  the  Hnes  of  incision.  Between 
each  pair  the  bowel  is  divided  by  scissors.  Two  clamps  will 
usually  be  quite  sufficient ;  indeed,  as  already  remarked,  the 
operation  may  be  performed  without  clamps  at  all. 

The  gut  may  be  removed  either  with  a  triangular  piece  of 
mesentery  or  along  the  mesenteric  border.  To  remove  a  wedge- 
shaped  piece  of  mesentery,  and  stitch  up  the  divided  margins, 
gives  a  surgical  finish  to  the  operation  which,  I  think,  is  of 
apparent  rather  than  of  real  value.  It  involves  less  division 
of  vessels,  and  so  induces  a  smaller  risk  of  subsequent  gangrene, 
to  leave  as  much  mesentery  as  possible.  It  may  be  gathered 
together  in  a  continuous  suture  under  the  line  of  intestinal 
junction  ;  and  if  a  few  superficial  sutures  are  placed  between 
the  broad  base  so  formed  and  the  intestinal  walls,  it  affords 
increased  breadth  and  security  of  apposition.  Especial  care 
must  be  taken  that  no  portion  of  bowel  be  left  without  attached 
mesentery.  In  experiments  on  animals,  Ryd3^gier  and  Madelung 
showed  that  gangrene  was  liable  to  occur  in  pieces  of  bowel 
protruding  beyond  the  mesenteric  attachment.  Zesas,''-'  con- 
tinuing and  extending  these  experiments,  found  that  gangrene 
always  followed  separation  of  the  mesenter}'-  close  to  the  un- 
divided bowel,  but  that  no  such  result  followed  when  the 
separation  was  made  at  a  distance. 

If  the  bowel  is  much  congested,  bleeding  from  the  divided 
vessels  is  likely  to  be  rather  sh_arp.  The  use  of  a  blunt  scissors 
will  lessen  this.  Forci-pressure  must  be  used  with  discretion: 
the  intestinal  walls  must  not  be  crushed — only  the  bleeding 
point  must  be  seized.  Tait's  sharp-pointed  forceps  are  the 
best  for  this  purpose. 

If  a  triangular  area  of  mesentery  is  removed,  the  gap  must 
be  carefully  closed  by  suture.  A  good  method  of  suturing  is 
the  continuous  overlapping  or  over-edging  stitch,  applied  over 
the  cut  ends  while  the  peritoneal  planes  are  held  in  apposition 
by  the  fingers.  A  double  row  of  continuous  sutures,  in  reversed 
order,  will  give  additional  security.  Catgut  would  be  quite 
efficient.  Treves  lays  particular  stress  on  the  accurate  suturing 
*  Arch.  f.  Klin.  Chir.,  1886,  Bd.  xxxiii.,  Heft  2. 


ENTERORRAPHY.  479 

of  the  mesenteric  gap,  so  as  to  prevent  occlusion  by  kinking 
at  the  line  of  junction.  For  the  same  purpose,  and  also  to 
minimise  the  risk  of  gangrene  at  the  free  edge  of  the  bowel, 
IMacCormac  recommends  an  oblique  division  of  the  gut,  more 
being  removed  from  the  free  than  from  the  mesenteric  side. 

Enterorvaphy. — Attention  is  now  turned  to  the  suturing  of  the 
divided  ends  of  bowel — Enterorraphy,  as  it  is  called.  This  is  a 
proceeding  as  delicate  and  tedious  as  it  is  important.  On  the 
accuracy  with  which  the  suturing  is  completed  depends,  more 
than  on  any  other  detail,  the  success  of  the  operation. 

Of  modes  of  suturing  there  is  quite  a  formidable  variety. 
Bishop,  in  a  valuable  paper  on  Enterorraphy,  ••'  has  collected  no 
fewer  than  thirt3^-three  distinct  methods.  Some  of  these  are 
simply  fantastic  ;  many  of  them  are  obsolete  ;  but  not  a  few  are 
brought  forward  with  the  authority  of  great  names,  and  at  least 
half  a  dozen  are  stamped  with  the  imprimatur  of  success. 

The  most  successful  method  will  be  in  harmony  with  the 
pathological  processes  of  union.     Though  it  would  be  erroneous 
to  deny  to  the  muscular  coat  all  power  of  exuding  plastic  13'mph, 
there  is  no  doubt  that  the  serous  coat  provides  adhesive  material 
in  far  greater  abundance  and  with  greater  rapidity.     As  a  me- 
dium of  union,  the  mucous  coat  may  be  ignored ;    but   as  a 
passive  plug  which,  when  it  falls  into  apposition,  prevents  the 
escape  of  intestinal  secretion,  it  may  be  of  great  use.  Apposition 
of  serous  surfaces,  as  continuous  as  possible,  and  inclusion  of  the 
muscular  coat,  not  only  to  strengthen  the  basis  of  attachment, 
but  to  prevent  the  retraction  which  takes  place  after  division, 
are  primary  elements  of  success.      More  in  detail,  the  essentials 
of  an  intestinal  suture  are  :  (i)  That  it  shall  secure  and  keep  up 
perfect  closure  of  the  wound  through  its  whole  extent.     The 
slightest  imperfection  in  apposition  will  permit  of  extravasation 
of  intestinal  contents ;    every  stitch,  therefore,  must  be  perfect. 
(2)  That  it  shall  be  of  material  which  is  unirritating,  and  that 
it  shall  have  a  known  and  durable  period  of  existence  in  the 
living  tissues.      Sutures  that  are  not  absolutely  pure  and  un- 
*  Med.  Chronicle,  Sept.,  1^85. 


480 


RESECTION  OF  INTESTINE. 


irritating  will  cause  suppuration,  as  will  tying  them  too  tightly. 
Certain  forms  of  prepared  catgut,  although  durable  enough,  are 
not  ver}'  pliable  or  very  smooth  ;  unprepared  gut  is  liable  to  be 
too  speedily  absorbed.  Fine  Chinese  twist  is  on  all  hands 
admitted  to  be  the  best  suture-material  for  divided  intestine. 

(3)  No  suture  passing  through  the  peritoneum  must  penetrate 
the  mucous  membrane.  This  would  practically  be  to  insert  a 
seton,  to  be  followed  by  a  fistula  between  the  cavity  of  the  gut 
and  the  peritoneum.  A  suture  involving  the  mucous  membrane 
should  alwa^'s  be  tied  on  the  inside  of  the  gut ;  if  it  suppurates, 
the  pus  passes  into  the  lumen  of  the  gut,  where  it  is  harmless. 

(4)  An  intestinal  suture  should  be  capable  of  being  rapidly 
inserted. 

Several  varieties  of  suture  satisf}^  these  requisites,  and  the 

most  useful  may  be  referred  to.      They  are  either  continuous  or 

interrupted,  or  mixed — that   is,   partly  continuous    and  partly 

interrupted. 

The  continuous  suture  has  its  advocates,  and  much  may  be  said 

in  favour  of  it.      It  affords  very  perfect  apposition,  it  is  quickly 

applied,  and  it  prevents  distension  of  the  bowel  and  so  opening 

of  the  spaces  between  the  stitches.      The  continuous  suture  has 

been  objected  to  because  it  remains  firm  only  so  long  as  each 

stitch  remains  secure,  and  that,  when  it  is  cast  off  inside  the 

bowel,  a  long  thread  remains  to  conduct  septic  material  into  the 

holes  in  which  it  still  lies.      The  second  objection  does  not  hold 

if  the  suture  is  placed  outside  in  the  serous  and  muscular  coats  ; 

and  the  first  is  not  a  strong  one  if  the  suture  is  properly  placed. 

The  best  continuous 

sutures     are,     in     my 

opinion,     those    of 

Dupuytren    (Fig.    60) 

and  Appolito  (Fig.  61), 

the  latter  modified  as  I 

suggest.     Dupuytren's 

^        ^  suture    gives     perfect 

Fig.  60.  ... 

apposition     of    serous 

Diifuytyen's  Continuous  Intestinal  Suture.  surfaces,     and     is    the 


ENTERORRAPHY. 


481 


most  easily  and  quickly  inserted  of  all.  The  suture  of  Appolito, 
modified  as  shown  in  the  diagram  to  avoid  the  necessity  of 
placing  a  body  in  the  intestine  to  which  the  end  of  the  ligature 
is  attached,  can  also  be  inserted  with  great  rapidity  after  a  little 
practice,  and  gives  wonderfully  accurate  apposition. 

There  is  one  objection  to  the  continuous  suture,  and  that  is, 


+  3 


8  7 

Fig.  6i. 

The  Intestinal  Suture  of  Appolito  modified. 

that,  if  the  bowel  contracts,  it  is  loosened  and  may  permit  the 
wound  to  gape.  As  a  sole  means  of  closing  the  ends  of  com- 
pletely divided  bowel,  the  continuous  suture  must  be  condemned ; 
but  as  an  extra  suture,  applied  over  specially  dangerous  parts, 

32 


482 


RESECTION  OF  INTESTINE. 


Fig.  62. 

Lembert's  Intestinal 
Suture. 


Fig.  63. 

Czerny's  Intestinal 
Suture. 


Fig.  64. 


Gnssenbaur' s  Intestinal 
Suture. 


to  give  additional  strength  arid  security, 
it  is  of  great  value.  Its  chief  virtues 
are,  that  it  can  be  quickly  applied, 
and  that  it  prevents  distension  of  the 
sutured  gut  and  possible  gaping  be- 
tween the  interrupted  sutures. 

Of  internipted  sutures,  the  best  known 
are  those  of  Lembert  (Figs.  52  &  62), 
Czerny  (Fig.  63),  and  Gussenbauer 
(Fig.  64).  In  Lembert's  method,  all 
the  sutures  are  placed  outside  the 
bowel :  this,  always  the  favourite 
method,  I  believe  to  be  still  the  best. 
Czerny's 


method 
combines 
Lembert's, 
with  the 
addition  of 
a  second 
row  pass- 
ing tiirough 
the  whole 
thickness 
of  the  gut 
and  tied  in- 
side. Gus- 
senbauer's  method  combines  the 
Czerny  and  the  Lembert  in  one 
suture,  but  does  not,  like  the  for- 
mer, traverse  the  mucous  membrane. 
Bishop  (Fig.  65)  has  introduced 
and  successfully  employed  in  the 
lower  animals  an  ingenious  and 
satisfactory  suture.  It  is  a  sort  of 
interrupted  shoemaker's  stitch  intro- 
duced on  the  mucous  aspect,  each 


m. 


/ffiSJ 


=.^.y^ 


'"^ 


m. 


fe^ 


Fig.  65. 

Bishop's  Intestinal  Suture. 


ENTERORRAPHY.  483 

suture-loop  being  tied  on  alternate  sides  of  the  line  of  junction. 
It  is  not  a  rapid  method  of  suturing,  nor  is  it  very  easy  of 
application ;  and  it  is  open  to  the  further  objection,  that  the 
sutures  are  all  on  the  mucous  aspect,  and  that  they,  by  their 
series  of  transverse  constrictions,  necessarily  cause  narrowing 
of  the  calibre.  I  believe  that,  as  a  subsidiary  suture  to  be 
applied  at  weak  parts,  Bishop's  is  of  great  value ;  but  as  a 
complete  suture  for  the  whole,  I 
think  it  might  be  excelled  by  others. 
Special  mention  must  be  made 
of  the  "quilt"  suture  of  Halsted."^' 
(Fig.  66.)  In  his  numerous  experi- 
ments he  found  it  the  best  of  all.  It 
takes  a  very  powerful  hold  of  the 
tissues,  and  will  bear  a  great  strain  ) 

without    causing   tearing :     on   this  Fig:  66. 

ground,  I   would  advise  its   use  in        nr  » .    j.    n?  •   ^    i^  o  . 

°        _  Halsteaa  s  Plain  Qmlt-Siituve. 

putting   the    parts   on    the    stretch 

for  the  application  of  the  Lembert  suture,  even  where  it 
is  not  employed  throughout.  The  "plain-quilt  stitches"  do 
not  produce  such  deep  apposition  as  the  "  buried-knot  half 
stitches."  Although  it  has  not  yet  been  proved  that  they  are  as 
good  as  the  Lembert  for  operations  on  the  human  subject,  still 
there  can  be  no  doubt  that  they  provide  us  with  a  very  strong 
and  easily  applied  method  of  suturing  which  may  he  employed 
to  supplement  other  methods. 

The  suturing  may  be  carried  out  either  while  one  or  other  of 
the  clamps  mentioned  is  on  the  ends  of  intestine  ;  or  by  the  aid 
of  the  fingers  alone,  small  sponges  being  placed  in  the  open 
ends  to  prevent  escape  of  the  intestinal  contents ;  or  while 
its  walls  rest  on  a  cylinder,  over  which  the  ends  of  bowel  are 
drawn. 

Of  such  cylinders  a  great  variety  has  been  suggested  and  used. 

The  trachea  of  an  animal ;  a  cylinder  of  tallow,  or  cacao  butter, 

or  dough,  or  isinglass,  or  such  liquefiable  material ;  a  decalcified 

hollow  bone ;  a  roll  of  oiled  cardboard,  and  other  materials  of 

*  Internat.  Jotmi.  of  Med.  Sc,  Oct.,  1887. 

32  =•■• 


484  RESECTION   OF  INTESTINE. 

allied  nature,  have  been  mentioned  or  used.  For  this  purpose 
the  sausage-shaped  soft  rubber  bag  invented  by  Treves  is  un- 
doubtedly the  best.  The  bag,  when  empty,  is  placed  in  the  open 
ends  of  the  bowel  and  inflated ;  when  the  last  stitches  are  about 
to  be  inserted  the  air  is  allowed  to  escape,  and  the  bag  is  removed 
collapsed  and  empty.  Most  surgeons,  however,  Treves  himself 
among  the  number,  regard  all  such  devices  as  unnecessary,  and 
place  the  stitches  without  the  introduction  of  any  foreign  body. 

Whilst  endeavouring  to  do  full  justice  to  everj^  good  method 
of  suturing  the  bowel,  I  may  be  permitted  to  describe  in  detail 
one  method  which,  for  ordinary  cases  of  resection,  is,  in  my 
opinion,  the  most  perfect.  This  method  will  most  easily  be 
comprehended  by  a  reference  to  the  accompanying  drawing, 
made  to  life-scale.    (Fig.  67.)    The  Lembert  suture  is  employed. 

The  diseased  intestine  has  been  cut  away,  the  mesentery 
being  divided  as  close  to  the  bowel  as  is  deemed  desirable,  and 
no  wedge-shaped  portion  being  removed.  Two  Makins'  clamps, 
covered  with  rubber-tubing,  have  been  applied,  at  a  distance  of 
about  half  an  inch  from  the  divided  ends  of  bowel.  A  purse- 
string  stitch  has  been  so  arranged  along  the  divided  margin  of 
mesentery  that  it  draws  together  the  gap  of  cellular  tissue 
and  the  attached  margins  of  gut,  while  it  leaves  free  small  flaps 
of  peritoneal  membrane  which  may,  if  deemed  desirable,  be 
grafted  on  to  the  base  of  the  line  of  union.  Four  quilt-sutures 
have  been  inserted  on  the  opposite  sides  of  the  divided  gut,  in 
the  exact  line  in  which  the  Lembert  sutures  are  to  be  placed  ; 
the  two  on  each  side  are  gathered  together  in  the  blades  of  catch- 
forceps,  and  gentle  and  steady  traction  made  on  them  by  an 
assistant.  This  raises  a  well-defined  fold  along  the  edge  of  the 
bowel ;  into  this  fold  the  sutures  are  inserted.  The  insertion  of 
these  quilt-stitches  makes  certain  that  equal  distances  of  the 
bowel  are  arranged  for  suturing,  and  also  by  raising  a  fold  makes 
the  insertion  of  stitches  more  easy,  and  ensures  their  being 
placed  in  a  straight  line.  The  whole  operation  is  carried  out 
while  the  parts  are  resting  on  a  warm  sponge-cloth  lying  on  the 
abdominal  wall,  and  while  several  sponges  packed  into  the 
cavity  keep  back  the  bowels.     The  assistant,  with  one  hand, 


ENTERORRAPHY. 


485 


holds  one  pair  of  forceps,  and   steadies  the  clamps  by  their 
extremities ;  with  the  other  he  holds  the  other  pair  of  forceps. 
About  a  dozen  ordinary  milliner's  needles  are  threaded  with 


Fig.  67. 

Drawing  to  show  method  0/  Intestinal  Suture. 
(For  description  see  Text.) 


486  RESECTION   OF  INTESTINE. 

the  fine  silk  selected  for  the  purpose.  Each  needle  carries 
sufficient  silk  to  make  three  sutures — say,  eighteen  inches  in 
length  altogether.  Three  stitches  may  be  placed  as  a  continuous 
uture  with  one  thread  eighteen  inches  long ;  the  loops  are 
divided,  and  another  threaded  needle  is  taken  up.  If  the  needle 
is  not  too  sharp,  the  insertion  of  the  sutures  may  be  carried  out 
with  great  practical  facility  and  almost  physiological  precision. 
Halsted's  statements  as  to  the  resisting  nature  of  the  strong 
fibrous  coat  are  verified  at  ever}^  stitch  :  it  is  scarcely  possible 
to  ignore  them.  The  needle  passes  readily  through  the  serous 
and  muscular  coats,  then  it  is  checked ;  a  rapid  change  from  the 
vertical  to  the  horizontal  position  picks  up  a  few  threads  of  the 
tough  fibrous  coat,  and  the  needle  emerges,  to  be  inserted  in  the 
same  way  on  the  other  side. 

Thus  the  sutures  are  placed  along  one  side  of  the  bowel 
between  the  quilt-sutures.  They  are  then  gathered  together  in 
the  hand  of  the  assistant,  as  in  closure  of  the  parietal  wound  in 
abdominal  section,  and  systematically  tied  from  one  end  to  the 
other.  Finally  the  quilt-sutures  are  tied,  the  four  threads  being 
either  tied  in  one  knot  or  in  two.  The  same  process  is  now 
carried  out  on  the  other  side,  and  the  operation,  so  far  as  the 
bowel  is  concerned,  is  completed.  The  gathered-up  layers  of 
mesentery  are  finally  inspected  ;  and  if  there  is  any  redundant 
tissue,  this  is  raised  as  far  as  possible  up  the  line  of  union  on  the 
intestine  and  fixed  there  by  a  suitable  stitch.  This  will  add  to 
the  strength  and  security  at  a  point  where  experience  has  shown 
it  to  be  specially  wanted. 

Senn's  mode  of  using  grafting  or  transplantation  of  the 
omentum  is  clearly  a  most  valuable  suggestion,  and  one  which, 
as  grafting  especially,  I  should  certainly  employ  where  possible 
in  every  case  of  resection.  Indeed,  wherever  a  wound  of  a 
hollow  viscus  has  to  be  closed,  it  will  add  to  the  security  if  we 
fix  the  omentum  by  a  few  stitches  over  the  sutured  wound.  I 
have  done  this  for  the  wound  in  the  stomach  made  for  dilatation 
of  the  pylorus. 

The  clamps  being  removed,  the  intestinal  contents  above 
them  are  permitted  and  encouraged  to  pass  downwards,  and  the 


ENTERORRAPHY.  487 

security  of  the  suture  carefully  tested.  At  any  point  which 
seems  weak,  a  continuous  Dupuytren's  suture  may  be  inserted. 
The  bowel  is  finally  cleansed  by  a  stream  of  warm  lotion,  and 
may  now  be  treated  in  one  or  other  of  three  ways : 

(i)  It  may  be  returned  into  the  abdominal  cavity,  the 
abdominal  wound  being  closed  over  it  in  the  ordinary  way. 

(2)  The  bowel,  carefully  protected,  may  be  left  outside  for  a 
few  hours  till  adhesive  inflammation  has  sealed  up  the  lines  of 
incision.  The  sutures  in  the  parietes  are  placed  in  position,  but 
not  tied  till  the  bowel  has  been  returned.  Schede  suggested  this 
plan ;  but  the  risks  of  distension  of  the  extruded  bowel,  and  of 
extrusion  of  more  bowel,  are  so  great,  that  it  has  not  generally 
been  adopted. 

(3)  The  sutured  bowel  is  returned,  and  fixed  by  a  stitch  or 
two  to  the  parietal  peritoneum.  The  abdominal  wound  is  left 
open  at  the  point  of  fixation,  but  closed  above  and  below. 
A  good  m.an}^  cases  which  have  recovered  have  done  so  after 
faeces  had  burrowed  an  opening  through  the  closed  parietal 
wound ;  and  some  have  died,  apparently  because  free  exit  was 
not  given  to  extravasated  intestinal  contents.  There  is  no 
strong  objection  to  this  plan ;  if  there  is  any  doubt  as  to  the 
perfection  of  the  suturing,  it  ought  to  be  followed. 

When,  however,  there  is  no  strong  reason  to  the  contrary, 
most  surgeons  prefer  to  completely  return  the  sutured  bowel 
into  the  cavity,  and  close  the  abdominal  wound  over  it. 

Where  suture  of  the  divided  ends  is  rejected,  on  account  of 
the  great  weakness  of  the  patient  forbidding  prolongation  of  the 
proceeding,  or  on  account  of  practical  difficulties,  an  artificial 
anus  is  formed.  This  is  done  by  bringing  both  ends  of  the 
bowel  out  through  the  abdominal  wound  at  a  convenient  point, 
and  suturing  them  to  the  wound-margin  and  to  each  other 
where  they  are  in  contact.  Great  accuracy  must  be  observed  in 
effecting  closure  of  the  openings  into  the  abdomen ;  and  when 
they  are  closed,  they  ought  to  be  liberally  smeared  with  some 
oleaginous  antiseptic  preparation. 

In  excision  of  the  large  bowel  a  few  points  demand  special 
notice.     It  is  rarely  possible  with  complete  satisfaction  to  re- 


488  RESECTION   OF  INTESTINE. 

move  a  piece  of  ascending  or  descending  colon  through  a  median 
incision.  In  several  cases  where  the  median  incision  has  been 
adopted,  a  supplementary  transverse  incision  has  been  requisite. 
As  it  matters  little  where  the  abdominal  incision  is  made,  this 
ought  to  be  always  over  the  tumour.  For  purposes  of  diagnosis, 
where  the  tumour  cannot  be  felt  through  the  parietes,  a  small 
median  incision  a  little  below  the  umbilicus  may  be  made  for 
the  insertion  of  the  forefinger.  When  the  site  of  the  tumour  is 
made  out,  a  resection  incision  may  be  made  at  a  suitable  spot 
and  the  exploratory  incision  closed.  The  incision  for  lumbar 
colotomy  is  not  a  satisfactory  one  for  resection  of  colon.  It  is 
too  deep  and  confined ;  the  wound  made  is  of  very  large  dimen- 
sions, and  through  a  lumbar  wound  it  is  not  easy  to  delimit  the 
amount  of  disease. 

The  after-treatment  of  these  cases  requires  no  special  com- 
ment. The  intestinal  movements  are  subdued  by  the  adminis- 
tration of  opium.  The  patient  is  nourished  by  artificially 
digested  foods,  which  are  absorbed  by  the  stomach  and  upper 
bowel,  and  which  leave  no  residue.  If  the  intestinal  wound  is 
high  up,  rectal  feeding  may  be  instituted.  For  the  rest  the 
treatment  is  as  in  ordinary  cases  of  abdominal  section. 


The    Formation    of   Intestinal    Anastomosis. 
Ileo- colostomy  ;    Colo  colostomy. 

As  an  extension  or  outcome  of  Wolfler's  operation  of  Gastro- 
enterostomy, similar  proceedings  have  been  carried  out  for  the 
estabhshment  of  fistulse  between  different  parts  of  the  intestines. 
The  indication  in  all  is  the  same,  an  obstruction  which  cannot 
be  removed,  and  the  aim  is  to  maintain  the  perviousness  of  the 
intestinal  tube  by  excluding  the  occluded  portion.  Billroth  and 
V.  Hacker*  have  performed  the  operation  of  Entero-colostomy 
for  cancer.  Langef  of  New  York  has  joined  the  ileum  to  the 
sigmoid  curvature  for  irreducible  invagination  in  an  infant.  W. 
Meyer,|  surgeon  to  the  German  Hospital  of  New  York,  has,  for 
cancer  at  the  hepatic  flexue  of  the  colon,  made  anastomoses 
between  the  ascending  and  the  transverse  colon.  The  cases 
of  V.  Hacker  and  of  Meyer  were  successful ;  the  latter  most 
strikingly  so.  Abbe§  of  New  York,  in  a  most  successful  case  of 
operation  for  complete  obstruction  caused  by  stricture,  performed 
Colo-colostomy  by  using  Senn's  decalcified  bone  plates.  It  is 
probable  that  all  operations  for  the  formation  of  intestinal  amas- 
tomosis  will  in  future  be  carried  out  by  the  use  of  absorbable 
discs  or  plates  for  causing  approximation.  The  difficulty  of 
getting  plates  of  bone  large  enough  for  use  in  the  human  sub- 
ject ;  the  trouble  necessary  for  their  preparation,  and  their 
tendency  to  warp  and  bend,  are  in  Abbe's  opinion  somewhat 
serious  drawbacks  to  their  general  employment,  and  he  suggests 
rings  made  of  several  threads  of  thick  catgut  wound  over  by  a 
spiral  of  the  same  material  as  substitutes.  These  would  not  give 
apposition  over  such  a  broad  surface,  but  they  would  certainly  be 
easily  prepared.  I  have  found  the  same  difficulty  with  the  bone 
plates  as  Abbe  has.  I  am  inclined  to  believe  that  the  plates 
would  be  more  easily  managed  and  equally  efficient  if  they  were 
not  dried  at  all,  but  placed  after  decalcification  directly  in  car- 
bolic solution  and  keeping  them  there  till  they  are  required. 

Scratching  the  serous  surfaces  with  a  needle  prior  to  approxi- 
mation was  found  to  promote  rapid  healing. 

*  IVien.  kUn.  IVoch.,  No.  17,  1888.         t  N.Y.  Med.  Rec,  Nov.  24,  1888. 
I  N.Y.  Med.  Rec,  Nov.  24,  1888.         §  N.Y.  Med.  Journ.,  Mar.  23,  1889. 


Operations  for  Artificial  Anus  and 
Faecal  Fistula. 

The  treatment  of  the  artificial  anus,  which  may  result  from 
any  of  the  above  operations,  demands  separate  consideration. 
In  those  cases  where  the  formation  of  artificial  anus  is  all  that 
was  intended  by  way  of  prolonging  life,  all  that  can  be  done  is 
to  attend  to  the  hygiene  of  the  opening.  In  others,  the  forma- 
tion of  false  anus  was  simply  one  step  towards  the  permanent 
cure ;  and  the  cure  of  this  fistula  is  attempted  at  the  proper 
time.  In  other  cases,  a  false  anus,  or  rather  a  faecal  fistula,  may 
result  from  the  yielding  of  stitches  after  enterorraphy,  and  an 
operation  to  cure  this  fistula  may  be  forced  upon  us. 

A  false  anus  may  be  described  as  an  opening  in  the  bowel 
which  forms  a  communication,  through  the  parietes,  between 
the  intestinal  canal  and  the  open  air.  The  bowel  around  this 
opening  is  adherent  to  the  parietal  peritoneum  over  a  varying 
extent  and  by  tissues  of  varying  thickness  and  density,  according 
to  the  amount  of  original  inflammation  and  the  standing  of  the 
case.  The  opening  in  the  parietes  to  which  the  gut  is  adherent 
is  of  varying  depth  and  size,  according  to  the  thickness  of  the 
parietes  and  the  position  where  the  bowel  has  become  adherent. 
Its  margins  are  puckered  and  depressed,  and  the  skin  around  it 
is  red  and  excoriated.  Sometimes  there  are  two  such  openings 
lying  close  to  each  other.  The  conditions  of  greatest  practical 
importance  are,  the  amount  of  bowel  which  has  been  lost,  and 
the  degree  of  flexure  of  the  two  intestinal  tubes  upon  them- 
selves. In  cases  where  artificial  anus  has  been  made  after 
resection  of  bowel  for  gangrene  or  disease,  two  pieces  of  intesti- 
nal tube  lie  parallel,  and  separated  from  each  other  by  their 
double  adherent  walls.  The  end  through  which  faeces  pass  will 
be  dilated ;  the  lower  end  will  be  collapsed,  shrivelled,  and 
empty.  Between  this  condition  of  parallelism  with  destruction 
of  bowel,  and  mere  slight  bending  with  a  hole  in  the  side  of  the 


VARIETIES   OF  ARTIFICIAL  ANUS. 


491 


gut,  there  are  many  varieties.  The  accompanying  diagrams 
(Fig.  68)  give  some  idea  of  these  varieties.  In  most  cases,  the 
continuity  of  the  bowel  above  and  below  the  fistula  is  in- 
terrupted by  a  spur  or  septum  [eperon  of  Dupuytren),  formed 
by  the  intestinal  walls  bent  inwards.  This  spur  varies  in 
dimensions  from  a  mere  elevation   or   flap  (Fig.  68,  II.),  to  a 

complete  barrier  to 
the  passage  of  faeces. 
(Fig.  6S,  III.)  It  in- 
creases in  size  with 
the  duration  of  the 
case,  being  dragged 
down  by  the  faeces 
and  pushed  over 
the  lower  collapsed 
bowel.  The  upper 
bowel  itself,  from 
its  constant  dis- 
charge of  function, 
becomes  increased 
in  size  and  more 
vascular ;  while  the 
lower  portion  may 
become  shrivelled 
to  the  size  of  fcetal 
life.  Hence,  it 
is  important  that 
any  operative  pro- 
cedures should  be 
done  early.  The 
exi  stence  of  this 
spur  is  the  chief  practical  difference  between  false  anus, 
which  discharges  the  whole  of  the  intestinal  contents,  leaving 
nothing  to  pass  into  the  lower  gut,  and  faecal  fistula,  which 
may  be  a  mere  opening  in  the  gut  without  flexure  upon  itself, 
and  permitting  extravasation  of  only  parts  of  the  contents.  In 
the  cure  of  false  anus,  this  spur  is  the  chief  obstacle :  if  fjecal 


Fig.  68. 

Diagrams  to  show  varieties  of  Artificial  Anus. 

U.  Upper  Bowel.  L.  Lower  Bowel.  I.  Pascal  Fistula, 
there  being  no  Spur.  II.  Faecal  Fistula  with  Spur.  III.  False 
Anus  with  Spur,  which  completely  shuts  off  the  Upper  from 
the  Lower  Bowel.    IV.  Double  Faecal  Fistula. 


492  OPERATIONS   FOR  ARTIFICIAL   ANUS. 

fistula  does  not  spontaneously  heal,  suturing  or  even  resection 
of  the  bowel  is  necessary. 

The  indications  for  operation  in  faecal  fistula  may  be  much 
stronger  than  a  mere  desire  to  get  cured  of  a  worrying  or  loath- 
some complaint.  If  the  opening  is  high  up  in  the  bowel,  rapid 
emaciation  from  escape  of  the  chyle,  and  death  from  inanition, 
may  be  apprehended.  The  urgency  of  symptoms  arising  from 
escape  of  nourishment  will  depend  upon  the  situation  of  the 
opening ;  but  it  seems  to  be  a  very  general  rule,  that  wasting 
is  to  be  expected  if  the  opening  is  anywhere  in  the  jejunum 
or  top  part  of  the  ileum.  Besides  this  danger,  patients 
with  false  anus  are  liable  to  prolapse  of  the  bowel  through 
the  opening,  or  even  to  ordinary  hernia. 

As  an  aid  to  the  diagnosis  of  the  situation  of  the  intestinal 
opening,  Senn's  method  of  inflation  by  hydrogen  gas  may  be 
employed  with  advantage.  If  the  gas  escapes  quickly,  and 
there  is  no  audible  gurgling  in  the  csecal  region,  the  fistula 
probably  enters  the  large  bowel.  If  the  gas  does  not  escape 
till  after  an  interval,  and  if  gurgling  is  heard  as  it  passes 
the  ileo-cffical  valve,  the  opening  is  probably  in  the  small 
bowel. 

Treatment. — The  mode  of  treatment  first  adopted  will  depend 
upon  the  nature  of  the  case ;  and  the  simpler  methods,  which 
promise  a  chance  of  cure,  are  put  into  use  before  the  more 
severe  plans.  The  modes  hitherto  recommended  may  be 
classified    as — 

(i)  Plastic  Closure,  by  pressure  or  plastic  operation  on  the 

faecal  opening. 
(2)  Depression,  division,  or  removal  of  the  spur,  to  restore 

the  patency  of  the  canal. 
3)  Resection  of  the  fistulous  portion  of  bowel,  and  suturing 

of  the  free  ends. 

(i)  The  mode  of  treatment  by  closing  the  f cecal  opening  is  em- 
ployed only  in  those  cases  where  there  is  no  spur,  or  where  it 
has   been   removed,    and   where  there   is   free   communication 


OPERATIVE   METHODS.  493 

between  the   upper  and   lower  segments  of  bowel.      It  would 
be  most  suitable  in  cases  of  fascal  fistula. 

Pressure  exerted  by  an  elastic  truss,  or  strapping  laced 
tightly  over  it,  so  arranged  as  to  bring  the  granulations  around 
the  fistula  into  apposition  and  keep  them  apposed,  has  in  some 
cases  effected  a  cure.  The  use  of  the  actual  cautery,  or  of 
some  caustic  material,  is  occasionally  effectual.  Fixing  the 
edges  in  apposition,  after  paring  them,  by  harelip  pins  or  silver 
wire  has  been  effectual.  If  all  these  fail,  an  attempt  to  close 
the  opening  by  a  plastic  operation  may  be  made.  What  form 
this  plastic  operation  will  take  must  depend  on  the  nature 
of  the  opening  to  be  closed  ;  but  I  believe  that  the  best  plan,  in 
most  cases,  would  be  by  two  flaps — one  turned  on  its  face  over 
the  opening,  and  the  other  laid  by  its  raw  surface  over  the 
surface  of  the  first.  The  fistula  should  be  drawn  as  closely 
together  as  possible  by  catgut  sutures  under  the  flaps,  so  as  to 
prevent  extravasation  of  faeces  into  the  uniting  portions ;  and 
the  under  flap  should  be  fixed  all  round  the  opening,  also  by 
catgut  sutures. 

(2)  By  removing  the  obstructing  spur  caused  by  the  infold- 
ing of  the  mesenteric  aspect  of  the  bowel,  and  so  permitting 
the  free  passage  of  the  intestinal  contents,  a  spontaneous  closure 
may  take  place.     This  may  be  done  in  various  ways. 

The  simplest  and  perhaps  the  best  method  is  by  the  inser- 
tion of  a  piece  of  thick  rubber  tubing  into  the  two  openings 
which  pushes  downwards  the  spur  by  its  continuous  efforts  to 
become  straight.  A  string  attached  to  it,  and  carried  out  of  the 
opening,  prevents  its  getting  out  of  reach.  Mitchell  Banks  has 
had  several  very  gratifying  successes  by  this  method.  It  is 
evidently  superior  to  the  older  methods,  by  tangle  tents  and  such 
like.  A  silver  tube  has  been  used  ;  but  it  may  be  very  difficult 
of  introduction,  and  may  even  produce  some  risk  of  perfora- 
tion. The  ends  of  the  rubber  tubing  may  be  cut  obliquely,  to 
facilitate  introduction  and  diminish  irritation  by  its  sharply  cut 
ends.  The  method  by  rubber  tubing  is  exceedingly  simple, 
quite  harmless,  and,  if  employed  early  enough  in  the  case,  full 
of  good  promise. 


494  OPERATIONS  FOR   ARTIFICIAL   ANUS. 

Gradual  division  of  the  spur  by  ligature  has  been  recommended 
and  practised  by  several  surgeons.  A  ligature  is  passed  through 
the  base  of  the  spur,  and  made  to  cut  its  wa}^  through.  As 
we  cannot  always  be  certain  that  peritoneal  surfaces  are  in 
adhesion  at  the  base  of  the  spur,  this  thread  may  be  carried 
into  the  peritoneal  cavity  and  set  up  peritonitis.  Dupuytren 
lost  a  patient  through  peritonitis,  after  the  use  of  the  scissors  to 
complete  a  cure  by  ligation,  and  he  abandoned  this  method.  It 
is  not  a  plan  to  be  recommended. 

Destruction  by  the  Enterotome. — Since  the  introduction  of  this 
instrument  by  Dupujrtren,  and  the  great  success  that  followed 
its  use,  the  mode  of  destroying  the  spur  by  slow  crushing  has 
enjoyed  a  considerable  amount  of  favour.  Dupuytren's  well- 
known  instrument  has  been  modified  and  improved  by  Blasius, 
Delpech,  Reybard,  Gross,  and  others.  Probably  the  best  of 
these  is  Gross's  enterotome,  which  not  only  divides  the  spur, 
but  removes  it.  Its  structure  is  simply  that  of  a  large  torsion 
forceps,  the  points  of  which  are  transformed  into  two  circular 
opposing  rings.  These  are  made  to  include  the  spur,  and  are 
left  till  the  compression  of  the  blades  cuts  their  wa}^  through, 
removing  the  greater  part  of  the  spur  between  them.  As  the 
compressed  portion  sloughs  away,  protective  inflammation  is 
set  up  in  the  neighbouring  peritoneum.  In  a  very  few  cases, 
however,  perforation  has  been  caused  by  the  enterotome,  and 
death  has  resulted.  This  ought  to  make  us  careful  in  ascertain- 
ing that  there  is  a  spur  with  at  least  some  amount  of  adhesion 
between  its  parts.  The  results  of  Dupuytren's  method  of  opera- 
ting are  very  favourable.  Herman*  has  collected  records  of  84 
cases,  with  a  mortality  of  only  8.5  per  cent.,  a  complete  cure  in  50 
cases,  and  in  26  considerable  improvement.  The  mortality 
is  so  small,  and  the  results  (if  trust woi thy,  which  is  just 
doubtful)  so  good,  that  the  method  of  treatment  ought  to  be 
adopted,  where  feasible  before  having  recourse  to  more  hazardous 
proceedings. 

After  any  of  the  above  proceedings  it  may  be  necessar}'  to 
close  up  the  opening  by  a  plastic  operation. 
*  Lond.  Med.  Rec,  1883,  p.   187. 


RESECTION   OF  INTESTINE.  495 

(3)  Resection  and  Suture  of  the  Intestine  is  a  grave  and  difficult 
proceeding,  to  be  adopted  only  when  all  other  methods  fail,  and 
when  the  patient  is  losing  ground  from  the  effects  of  the  com- 
plaint. It  may  be  indicated  in  cases  where  there  are  several 
faecal  fistulas,  with  several  openings  in  the  bowel  which  cannot 
be  closed  by  the  ordinary  modes  of  treatment.  In  cases  of  large 
loss  of  substance  of  one  side  of  the  bowel,  without  flexure  and 
without  the  existence  of  a  spur,  resection  may  from  the  first 
afibrd  the  only  prospect  of  cure.  Again,  when  there  is  extensive 
prolapse  of  the  mucous  membrane  which  cannot  be  controlled, 
and  which  is  causing  ulceration  or  inflammation  of  the  bowel, 
resection  may  be  indicated. 

Mr.  G.  H.  Makins*  has  made  a  laborious  and  complete  list 
of  all  the  recorded  cases  of  enterectomy  for  artificial  anus.  Out 
of  39  cases  where  the  operation  was  performed  for  this  purpose, 
15  (38.4  7o)  died  of  the  operation.  Of  the  fatal  cases,  9  died  of 
septic  peritonitis — 5  of  which  were  from  faecal  extravasation,  in 
3  cases  from  the  mesenteric  border.  Of  the  24  that  recovered, 
3  were  left  with  artificial  anus.  These  results  are  sufficiently 
encouraging,  and  more  than  justify  the  proceeding  in  cases  such 
as  those  indicated. 

The  proceeding  so  carefully  planned  and  so  skilfully  carried 
out  by  Makins,  seems  to  me  to  fulfil,  as  far  as  possible,  the 
best  principles  of  surgery,  and  the  following  description  is  based 
on  his  account  of  his  case : 

Preliminary  proceedings,  to  permit  of  operation  with  an 
empty  bowel  and  a  pure  wound,  will  be  instituted.  For  a  couple 
of  days  or  so  before  operation  the  patient  is  to  be  fed  upon 
nutrient  enemas,  all  food  by  the  mouth  being  withheld.  Just 
before  the  operation  the  bowel  may  be  irrigated  with  warm 
water  till  the  fluid  returns  clear.  If  it  is  possible  to  wash  out 
the  lower  bowel  as  well  as  the  upper,  this  had  better  be  done. 
The  fistula  and  the  parts  surrounding  may  be  kept  soaking  for 
twenty-four  hours  or  so  before  operation  in  carbolic  lotion,  as 
strong  as  can  be  borne  without  causing  smarting — probably 
about  1-30.  When  the  patient  is  anaesthetised,  the  surrounding 
*  St.  TJios.  Hos.  Rep.,  vol.  xiii.,  1884,  p.   181. 


496  \OPERATIONS  FOR   ARTIFICIAL   ANUS. 

skin  is  to  be  scrubbed,  first  with  turpentine  and  then  with  1-20 
carboHc  lotion,  by  means  of  a  nail-brush.  All  granulations 
are  to  be  scraped  off  or  scrubbed  off,  and  their  site  thoroughly 
purified.  The  spray  may  now  be  turned  on,  and  the  opera- 
tion proceeded  with,  in  the  expectation  of  its  being  an  aseptic 
one. 

An  incision,  vertical  by  preference,  is  made  through  the 
abdominal  walls  for  about  an  inch  and  a  half  on  each  side  of  the 
fistula — more  or  less,  as  circumstances  render  expedient.  The 
cavity  being  opened,  the  condition  of  the  entering  and  returning 
bowel  is  inspected — their  relations,  the  amount  and  nature  of 
the  adhesions  present,  and  so  forth.  The  ends  are  now  care- 
fully dissected  away  from  their  adhesions,  liberated,  and  drawn 
through  the  wound.  After  the  abdominal  cavity  is  opened,  the 
chance  of  extravasation  of  the  intestinal  contents  may  be  pre- 
vented by  the  insertion  of  a  sponge,  or  the  placing  of  two  clamp- 
forceps  round  the  wound,  or,  perhaps  best  of  all,  by  grasping 
the  bowel  around  the  opening  by  a  Nelaton's  or  other  suitable 
forceps  and  leaving  it  attached  there.  When  the  bowel  is  pulled 
out  so  far  as  to  give  freedom  for  the  application  of  the  sutures 
after  it  has  been  resected,  the  abdominal  cavity  is  to  be  closed 
as  far  as  possible  by  the  packing  in  of  sponges.  A  large  sponge 
would  with  difficulty  be  inserted ;  but  several  strips  of  flat 
sponge,  or  several  small  sponges  tied  together,  will  serve  the 
same  purpose.  When  the  opening  is  satisfactorily  closed,  the 
clamp-forceps  are  put  on — one  on  each  side  of  the  two  incisions 
— and  the  bowel,  with  the  fistula  in  it,  is  cut  away  with  scissors 
beyond  the  site  of  the  old  adhesions.  The  mesentery  being 
united  by  a  double  row  of  continuous  suture  if  a  triangular 
piece  has  been  removed ;  or  by  a  purse-string  suture  if  no 
mesentery  has  been  removed,  the  suturing  of  the  divided  ends  is 
now  proceeded  with.  If  the  two  ends  of  bowel  are  of  very 
different  calibre,  as  is  frequently  the  case,  some  difficulty  in 
getting  apposition  may  be  apprehended.  The  lower  opening 
may  be  gently  dilated  to  a  slight  extent  by  the  fingers,  and  this 
may  suffice ;  but  it  may  be  necessary  to  cut  the  lower  bowel 
obliquely  away  from  its  mesenteric  attachment,  so  as  to  increase 


THE   OPERATION.  497 

the  area  to  be  sutured.     The  suturing  is  carried  out  exactly  as 
for  ordinary  enterectomy,  already  described. 

If,  after  the  bowel  has  been  sutured,  it  is  found  impossible 
to  bring  together  the  edges  of  the  fistulous  opening,  it  may  be 
wise  to  complete  the  closure  of  the  abdominal  wound  by  a 
plastic  operation.  As  to  dressing,  nothing  need  be  added  to  the 
accounts  already  given. 


33 


Section  VIII. 


OPERATIONS   ON   THE   KIDNEYS. 


The  surgery  of  the  kidneys  might  be  arranged  under  the  three 
heads  of  incision,  renioval,  and  fixation.  Incision  is  performed 
for  the  evacuation  of  cystic  and  purulent  collections,  and  for  the 
removal  of  stone :  the  first  class  of  operations  is  known  by  the 
name  Nephrotomy  (i/e0yoo's — kidney,  and  Tojur] — incision) ;  the 
second  is  specialised  as  Nephro-lithotomy  {ve<pp6^,  X/i9os- — stone, 
Tojut'i).  The  kidney  may  be  removed  for  any  of  the  conditions 
which  justify  nephrotomy,  and  specially  for  solid  new  growths. 
The  operation  of  excision  of  the  kidney  is  named  Nephrectomy. 
Operative  fixation  of  a  movable  kidney  is  named  Nephrorraphy 
()'G0/>o»,  pa(p7j — suture).  As,  however,  stitching  is  not  an  essen- 
tial part  of  the  operation  for  fixing  a  movable  kidney,  some  other 
word,  such  as  Nephropexis  {Trijrf,,v^a — fix),  would  be  more  exact. 
Nephrorraphy  is  properly  applicable  to  the  stitching  up  of 
wounds  in  the  kidney. 


SURGICAL   ANATOMY.  49» 


SURGICAL    ANATOMY    OF    THE    KIDNEYS. 

The  size  of  the  kidney  in  health  is  about  4  inches  in  lengthy 
2^  inches  in  breadth,  and  between  ij  and  i^  inch  in  thickness. 
The  right  kidney  is  a  Httle  shorter  and  broader  than  the  left. 

The  kidneys  lie  deep  in  the  lumbar  regions,  embedded  in 
capsules  of  fatty  tissue.  Each  kidney  overlies  portions  of  the 
diaphragm,  the  transversalis  aponeurosis,  and  the  psoas  muscle. 
Vertically,  the  position  of  the  kidneys  is  liable  to  some  variation 
in  health  and  in  disease.  Morris*  says  that  "  the  upper  edge  of 
the  kidney  corresponds  with  the  space  between  the  eleventh  and 
twelfth  ribs,  and  the  lower  edge  is  nearly  on  a  level  with  the 
middle  of  the  third  lumbar  spine."  This  is  probably  correct : 
it  certainly  corresponds  with  a  good  many  observations  which  I 
have  made.  Braune  places  them  in  similar  position,  the  left 
being  a  little  higher.  Luschka's  observations  correspond,  or 
place  them  about  half  an  inch  higher  still.  The  ordinary  de- 
scriptions in  the  text-books  place  them  about  half  a  vertebra  too 
low.  The  level  of  the  hilum,  the  part  which  concerns  us  most, 
is  practically  that  of  the  first  lumbar  vertebra ;  that  is,  just 
clear  of  the  ribs  behind,  and  overlapped  by  the  floating  ribs  in 
front. 

The  long  axis  of  the  kidney  is  not  accurately  vertical,  nor 
are  its  surfaces  anterior  and  posterior.  This  will  be  best  under- 
stood by  saying  that  if  the  vertical  axes  were  prolonged  upwards, 
they  would  meet  near  the  surface  of  the  body  behind  at  an  angle 
of  about  forty  degrees ;  while  if  the  transverse  axes  were  pro- 
longed forwards,  they  would  meet  in  front  of  the  vertebral 
column  at  an  angle  of  about  sixty  degrees.  The  upper  end  lies 
deeper  and  nearer  to  the  spine  than  the  lower.  It  might  truth- 
fully be  said  that  the  surface  known  as  the  anterior  has  just  as 
much  right  to  be  known  as  the  exterior. 

The  right   kidney,  on  its  upper  and    anterior    aspect,  is  in 
contact    with   the    under  surface  of  the  liver.     This  fact  may 
explain  its  slightly  lower  position,  and  its  greater  tendency  to- 
become  displaced.     In  direct  contact  with  its  anterior  surface, 
*  Surg.  Dis.  of  Kidneys,  p.  2, 
33  * 


500 


OPERATIONS   ON   THE   KIDNEY. 


where  they  are  uncovered  by  peritoneum,  are  the  duodenum  and 
the  junction  of  the  ascending  with  the  transverse  colon.  The 
top  of  the  left  kidney  touches  the  fundus  of  the  stomach :  the 
upper  two-thirds  of  its  external  border  is  in  relation  with  the 
spleen ;  in  front,  towards  the  inside,  lies  the  pancreas ;  and 
crossing  its  anterior  surface  lower  down,  is  the  beginning  of  the 
descending  colon.  The  position  of  the  colon  in  relation  to  the 
kidney  is  of  importance  in  diagnosis,  as  well  as  in  operation. 
When  the  kidney  becomes  enlarged,  the  colon,  bound  down  to 
it  under  the  same  peritoneum,  is  carried  in  front  of  it.  Renal 
tumours,  of  necessity  growing  downwards,  burrow  under  the 
colon  and  push  it  forwards.  On  the  right  side  the  ascending 
colon  is  usually  found  to  lie  vertically  on  a  renal  growth;  on  the 
left  side,  the  transverse  and  the  descending  colon  pass  obliquely 
in  curvilinear  direction  from  above  downwards  and  outwards. 
In  the  layer  of  peritoneum  which  passes  backwards  from  the 
colon  to  the  mesentery  lie 
the  vessels  which  supply 
the  colon;  and  any  serious 
injury  to  these  vessels, 
such  as  might  be  caused 
by  peeling  peritoneum  off 
renal  growth,  is  fraught 
with  danger  to  the  vitality 
of  that  portion  of  bowel. 
The  peritoneum  which 
passes  from  the  colon 
over  the  tumour  towards 
the  abdominal  wall  may 
be  divided  without  fear 
of  injuring  the  vascular 
supply  of  the  bowel. 

The  structures  at  the 
hilum    (Fig.   69)   of   the  Fig.  69.     (After  Weisse.) 

kidney— the     artery,    the       structures  in  the  Hilum  of  the  Left  Kidney 
vein,  and  the  ureter — are  viemd  from  behind. 

of    special      importance,  a,  Artery ;  V,  Vein ;  P,  Pelvis ;  U,  Ureter. 


SURGICAL   ANATOMY.  501 

because  they  form  the  pedicle  in  cases  of  extirpation.  The 
direction  of  the  vessels  from  the  aorta  and  the  vena  cava  is 
practically  transverse.  The  right  artery  ascends  a  little  to  its 
kidney,  its  origin  from  the  aorta  being  a  little  lower  down  than 
the  left ;  it  is  also  longer  than  the  left,  owing  to  the  position  of 
the  aorta  to  the  left  of  the  middle  line.  The  right  artery  passes 
behind  the  vena  cava.  Just  before  entering  the  hilum,  where 
the  vein  is  said  to  lie  in  front  and  the  ureter  behind,  the  artery 
breaks  up  into  four  or  five  branches,  which  are  distribiited  to  the 
renal  tissue.  These  branches  may  occupy  any  position  in  front 
of,  behind,  or  by  the  side  of  their  corresponding  veins.  Small 
branches  are  given  off  to  the  supra-renal  body,  the  ureter,  and 
the  neighbouring  connective  tissue.  The  renal  veins  are  a  good 
deal  larger  than  the  arteries,  and  overlap  them.  The  left  vein  is 
longer  than  the  right,  having  to  cross  the  aorta  to  enter  the 
vena  cava.  Into  this  vein  the  left  spermatic  and  the  left  inferior 
phrenic  veins  discharge  themselves  (Fig.  70) :  both  vessels  are 
quite  within  reach  of  injury  in  dealing  with  the  renal  pedicle.  At 
the  hilum  the  veins  branch  quite  as  much  as  the  arteries,  and 
the  subdivision  extends  farther  towards  the  middle  line.  In  the 
post-mortem  room,  in  about  twenty  subjects  examined  on  this 
point,  I  have  been  surprised  at  the  frequenc)^  with  which  two  or 
more  trunks  represent  the  renal  vein,  sometimes  surrounding  the 
artery.  Variations  in  the  artery  are  by  no  means  rare.  This 
want  of  uniformity  in  the  renal  vessels  is  against  the  possibility 
of  ligaturing  artery  and  vein  separately.  In  scratching  or  cut- 
ting open  the  pelvis  of  the  kidney,  it  is  quite  possible  to  wound 
a  vein.  Though  the  kidney  is  a  very  vascular  organ,  yet,  as  its 
vessels  run  in  a  straight  course  towards  the  convex  border,  and 
do  not  anastomose  to  any  extent,  an  incision  may  be  made  from 
cortex  towards  hilum  without  causing  dangerous  bleeding.  The 
accompanying  drawing  (Fig.  70)  is  an  accurate  representation 
of  the  photograph  of  a  dissection  specially  made  to  show  the 
relations  of  the  parts  concerned  in  operations  on  the  kidneys. 
It  will  be  noted  that  on  both  sides  the  renal  veins  dip  behind 
the  arteries,  and  enter  the  hilum  between  them  and  the  ureters. 
This  is  not  as  the  books  on  Anatomy  put  the  relations;  but  as 


602 


OPERATIONS   ON   THE   KIDNEY. 


in  four  bodies  in  which  I  have  carefull}'  looked  into  this  point, 
and  in  a  good  many  more  in  which  I  have  made  rough  post- 
mortem investigations,  I  have  always  found  it  so — that  is  to  say, 
always  artery  in  front  and  vein  behind, — the  relations  figured 
must  be  common.     The  breaking-up  of  the  renal  arteries,  soon 


F'iG.   70. 

Drawing  of  dissection  made  to  show- relations  of  parts  in  operations 
on  the  Kidneys. 

R.  K.  Right  Kidney.  L.  K.  Left  Kidney.  Ao.  Aorta.  V.  C.  Vena  Cava.  Ph.  Left 
inferior  Phrenic  Vein.  2  and  2.'  Left  and  Right  Renal  Arteries.  3  and  3.'  Left  and  Right  Renal 
Veins.  4  and  4.'  Leftand  Right  Spermatic  Veins.  5and5.'  Left  and  Right  Spermatic  Arteries. 
6.  Mesenteric  Vessels.    7  and  7.'   Left  and  Right  Ureters. 

after  leaving  the  aorta  on  the  right  side  and  before  entering  the 
hilum  on  the  left,  is  a  common  arrangement. 

At  the  lower  border  of  the  kidney  the  ureter  begins  to  expand 
into  the  funnel-shaped  sac  known  as  the  pelvis.  In  the  hilum 
the  pelvis  gives  off  two  or  three  short  trunks,  which  in  their 
turn  subdivide  and  form  the  catyces  or  infundibula  which  open 
over  and  grasp  the  papillae.  Jordan  Lloyd'''  has  found  that 
many  of  the  primary  tubes  are  more  than  an  inch  in  length, 
*  Birm.  Med.  Rev.,  Dec,  1886. 


SURGICAL   ANATOMY. 


603 


and  no  larger  than  a  No.  lo  catheter  ;  while  the  secondary 
tubes  run  as  fine  as  a  knitting-needle.  In  such  cases,  it  is 
evident  that  a  finger  inserted  into  any  part  of  the  pelvis  could 
not  possibly  make  a  complete  examination  of  the  calyces ;  and, 
on  the  other  hand,  it  may  be  added,  that  a  stone  impacted  in 
one  of  the  primary  tubes  could  not  be  removed  through  a 
secondary  tube  opened  up  by  an  incision  confined  to  the  renal 
structure.    The  accompanying  drawing  (Fig.  71),  which  is  more 

true  to  nature  than  any  I  have 
seen,  shows  clearly  the  truth  of 
Mr.  Lloyd's  contention. 

The  pelvis  passing  downwards 
and  inwards  from  the  hilum, 
gradually  contracts  to  form  the 
ureter.  The  ureter  is  said  to 
begin  at  the  lower  border  of  the 
kidney,  and  passes  downwards 
and  inwards  behind  the  peri- 
toneum to  its  insertion  into  the 
base  of  the  bladder.  From 
above  downwards,  it  is  in  rela- 
tion with  the  psoas  muscle  and 
the  genito-crural  nerve ;  at  the 
brim  of  the  pelvis,  it  crosses  the 
external  iliac  vessels  on  the 
right  side,  and  the  common  iliac 
vessels  on  the  left ;  thence  it 
passes  in  the  fold  forming  the 
posterior  false  ligament  of  the 
bladder  to  its  insertion.  All 
through  its  course  the  ureter 
is  very  loosely  attached  to  the 
cellular  tissue  in  which  it  lies. 

The  kidney  is  kept  in  position 

by   its  thick    packing   of    fatty 

cellular  tissue,  known  as  the  tunica  adiposa.     This  tissue  varies 

in  amount  in  different  individuals ;  but  it  is  always  of  consider- 


FiG.  71,     (Heitzmann). 

Pelvis  and  Calyces  of  the  Kidney  pre- 
pared out  of  the  Renal  Substance. 


I.   Minor  Calyces. 
3.  Pelvis.      .).   Ureter 


Major  Calyces. 


504 


OPERATIONS   ON   THE  KIDNEY. 


able  thickness.  In  this  elastic  bed,  the  kidney  enjoys  some 
liberty  of  movement ;  when  it  is  opened  up,  and  the  kidney  is 
exposed,  regular  movements  are  seen  to  follow  the  respiratory 
acts.  When  the  fat  is  partly  absorbed,  or  its  density  is  dimin- 
ished, anatomical  displacements  may  be  produced. 

In  operations  upon  the  kidney,  the  lowest  limits  of  the  pleura 
and  its  relations  to  the  twelfth  rib  are  of  importance.  Dum- 
riecher  of  Vienna,  in  an  operation  upon  an  enlarged  kidney,  by 
misadventure  opened  the  pleura.  Holl  of  Vienna  and  Lange  of 
New  York  have  made  studies  on  this  point,  which  show  that  the 
last  rib  is  frequently  so  short  as  to  be  overlooked,  and  that  the 
pleura  descends  as  low  as  if  the  twelfth  rib  were  of  normal  length. 
(Fig.  72.)     The  lower  edge  of  the  pleura  passes  horizontally 


Fig.  72.     (Lange.) 

Hovizo7ital  Section  of  Body  between  Second  and  Third  Lumbar  Vertebrce  (surface 
of  Upper  Section  seen  from  below,  i.e.  right  side  to  left  hand),  shoiving  relations 
of  Kidneys  to  Peritoneum  (marked  by  dotted  lines)  and  Muscles. 


between  the  lower  boundary  of  the  twelfth  dorsal  vertebra  and 
the  lower  edge  of  the  eleventh  rib,  whatever  be  the  condition  of 
the  twelfth  rib.  It  is  peculiarly  necessary,  therefore,  that  the 
upper  limits  of  incision  should  be  marked  rather  by  counting 
the  ribs  before  operation,  than  by  feeling  the  presence  of  the 
bony  rim  during  operation. 


Nephrorraphy. 

By  this  operation  is  meant  the  fixation  of  a  kidney  that  is 
movable.  It  need  not  be  the  replacement  of  a  misplaced  kidney; 
nor  does  the  operation,  as  already  remarked,  of  necessity  involve 
the  placing  of  sutures.  With  simple  misplaced  kidney,  congenital 
or  acquired,  we  have  here  nothing  to  do :  the  existence  of  such 
a  condition  is  usually  discovered  for  the  first  time  in  the  post- 
mortem room.  It  is  where  there  is  not  only  displacement  but 
want  of  fixation,  and  where  this  mobility  begets  troublesome 
symptoms,  that  the  operation  to  be  described  may  be  called  for. 

Pathological  Anatomy  of  Movable  and  Floating  Kidney. — Two 
forms  of  displaced  and  not  fixed  kidneys  are  described — 
Movable  Kidney  and  Floating  Kidney.  In  Movable  Kidney, 
the  movements  are  entirely  sub-peritoneal ;  they  take  place  in 
a  space  artificially  created  in  the  areolar  tissue  which  binds  the 
peritoneum  to  the  underlying  muscles.  In  Floating  Kidney, 
the  movements  are  intra-abdominal ;  that  is  to  say,  the  kidney 
is  surrounded  by  peritoneum,  and  possesses  a  meso-nephron. 
The  former  is  acquired ;  the  latter  is  congenital. 

Movable  Kidney. — A  certain  amount  of  mobility,  to  the  extent 
of  an  inch  or  an  inch  and  a  half,  is  not  v  y  uncomnjon,  espe- 
cially in  women  with  flaccid  abdominal  walls  who  have  borne 
a  large  number  of  children.  Here  the  mobility  of  the  kidneys 
is  of  a  piece  with  want  of  stability  in  the  position  of  other 
abdominal  organs,  and  is  of  no  practical  moment.  In  greater 
degree  the  mobility  may  be  associated  with  certain  changes  in 
the  tissues  which  are  in  immediate  relation  with  the  kidneys, 
and  in  some  instances  with  changes  in  the  tissue  of  the  organ 
itself. 

The  kidney  moves  behind  the  peritoneum  in  a  loose  bed, 
which,  according  to  Newman,  may  be  formed  in  various  ways. 
The  adipose  tissue  which  closely  envelops  it  may  become 
loosened  all  round,  and  the  kidney  may  move  about  in  the 


606  NEPHRORRAPHY*, 

potential  space  so  created.  Or,  the  fatty  tissue  immediately 
surrounding  the  kidney  may  remain  undisturbed,  while  the 
kidney  with  its  fatty  capsule  may  move  in  a  space  formed  by 
the  separation  of  peritoneum  in  front  from  muscle  behind.  Or, 
there  may  be  a  double  mobility  inside  the  capsule  and  behind 
the  peritoneum.  In  every  case  there  will  probably  be  a  notable 
diminution  of  circumrenal  fat.  In  a  considerable  number  of 
cases  lengthening  of  the  renal  vessels  has  been  found. 

The  amount  of  mobility  varies  from  an  inch  or  two,  to  the 
extreme  distance  which  the  double  attachment  of  renal  vessels 
and  ureter  will  permit. 

The  movable  kidney  is  usually  perfectly  healthy  ;  but  occa- 
sionally lesions  are  found  in  an  association  with  mobility  which 
can  scarcely  be  regarded  as  other  than  one  of  cause  and  effect. 
Thus,  Dickinson*  has  found  pyelitis  associated  with  movable 
kidney;  and  Fritz!  relates  a  similar  association,  both  in  his 
own  experience  and  in  that  of  Urag.  Landau  |  punctured 
many  times  a  hydro-nephrosis  in  a  movable  kidney,  which 
ultimately  became  purulent,  and  was  successfully  opened  and 
drained.  Hickinbotham  had  a  case  of  death  from  pyelitis  in  a 
wandering  kidney.  Kehrer  traces  a  connection  between  blocking 
of  the  ureter  of  a  movable  kidney  by  torsion  or  kinking,  and 
hydro-nephrosis.  In  this  category,  as  a  probable  cause  of  hydro- 
nephrosis, Dickinson  places  calculus  or  gravel,  and  further 
offers  the  suggestion  that  temporary  dilatations  of  the  pelvis  by 
an  obstructing  calculus,  by  increasing  the  size  of  the  organ, 
may,  when  the  swelling  disappears,  cause  loosening  of  the 
kidney  in  its  bed,  and  so  start  the  mobility.  Pyelitis  may  thus 
be  a  cause  of  mobility.  In  such  cases  peri-nephritis  may  be  set 
up  :  occasionally  this  is  so  severe  as  to  cause  adhesion  to  neigh- 
bouring organs,  and  especially  to  the  liver. 

Tumours,  cystic  and  malignant,  have  been  found  associated 
with  mobility  of  the  kidney.  Menstruation  has  by  several 
observers  been  noted  as  a  possible  cause  of  temporary  increase 
in  the  size  of  the  kidney.     Sawyer,  in  particular,  called  atten- 

*  Renal  and  Urinary  Affections,  vol.  iii.,  1883.    t  Archiv.  Gen.  de  Mdd.,  1859,  vol.  ii. 
\  Die  Wanderniere  der  Franen,  Berlin,  1881. 


PATHOLOGICAL   ANATOMY.  507 

tion  to  this  ;  and  Newman  found  an  aggravation  of  the  symptoms 
in  a  movable  kidney  during  menstruation,  while  he  thought  he 
also  detected  an  increase  in  its  size. 

The  condition  usually  appears  during  adult  life  or  middle 
age,  and  is  extreme^  rare  in  childhood  and  in  old  age.  Of  290 
cases  collected  by  Newman,  81  per  cent,  occurred  between  the 
ages  of  20  and  50.  It  is  six  or  seven  times  more  common  in 
women  than  in  men,  according  to  the  investigations  of  Newman, 
Roberts,  Ebstein,  and  Dickinson.  The  right  kidney  is  affected 
four  times  more  frequently  than  the  left ;  rarely  are  both  affected 
at  the  same  time. 

From  the  fact  that  movable  kidney  is  most  frequently  found 
in  v.'omen  who  have  borne  children,  it  has  been  inferred  that 
pregnancy  is  a  cause.  It  would  probably  be  more  exact  to  say 
that  laxity  of  abdominal  walls,  whether  it  follow  pregnancy  or 
not,  favours  the  displacement.  Absorption  of  circumrenal  fat 
is  another  cause :  such  a  case,  a  very  marked  one,  appeared  in 
the  post-mortem  room  of  the  Bristol  Infirmary  three  years  ago. 
In  this  case  cancer  of  the  stomach  was  the  cause  of  emaciation. 
Dickinson  records  cases  in  which  accident  or  severe  strain 
seemed  to  start  the  mobility. 

Speaking  generally,  movable  kidney  is  most  likely  to  be 
induced  by  a  combination  of  circumstances.  The  most  telling 
combination  would  be  found  in  a  middle-aged  woman,  accus- 
tomed to  severe  manual  labour,  who  has  borne  several  children 
in  rapid  succession,  and  who  is  losing  flesh.  When  once  the 
kidney  is  started  from  its  bed,  repeated  movements  or  jerks  in- 
crease the  mobility.  The  influence  of  suck  jerks  is  cumulative  : 
every  inch  gained  adds  to  the  ease  with  which  another  inch  is 
gained,  till  its  limits  of  mobility  are  reached,  when  it  drags  upon 
its  own  vessels  and  ureter. 

Floating  Kidney. — A  floating  kidney  has  been  defined  by 
Jenner'^'  as  one  "  that  has  a  mesentery,  a  fold  of  peritoneum- 
attaching  it  very  loosely  to  the  spine."  It  is,  indeed,  probable 
that  this  definition  is  too  precise.  The  investigations  recently 
carried  out  under  the  auspices  of  the  Pathological  Society  of 
*  Brit.  Med.  Journ.,  1869,  ^'o^-  i-i  P-  43' 


508  NEPHRORRAPHY. 

London  would  seem  to  show  that  one  variety  of  displacement 
may  merge  into  another,  or  rather  that  a  movable  kidney  may 
so  drag  out  its  peritoneal  covering  as  almost  to  cause  the  forma- 
tion of  a  meso-nephron.  To  surgeons,  as  Morris  very  properly 
points  out,  the  main  consideration  is,  whether  or  not  the  kidney 
has  a  meso-nephron ;  that  is,  whether  it  can  be  reached  by  an 
extra-peritoneal  operation  from  the  loin. 

Floating  kidney  is  very  rare.  It  is  always  congenital,  and  is 
frequently  associated  with  other  abnormalities  in  the  disposition 
of  the  peritoneum.  In  at  least  two  described  cases,  malforma- 
tion of  the  large  intestine  has  been  found.  The  renal  vessels 
have  been  found  elongated.  General  laxit}'  of  the  peritoneum 
has  been  found  in  more  than  one  case  of  true  floating  kidney. 

Symptoms. — The  subjective  signs  of  movable  kidney  range 
from  mere  discomfort  to  intense  pain.  The  symptoms  tend  to 
vary  according  to  the  amount  of  mobility.  Thus,  slight  degrees 
of  mobility  may  be  troublesome  only  after  undue  effort  or  exer- 
cise ;  extensive  mobility  rarely  leaves  the  patient  free  from  pain, 
and  is  often  associated  with  positive  agony. 

The  most  common  symptom  is  a  dull,  aching  or  dragging 
pain  in  the  loin,  shooting  down  the  abdomen  towards  and  along 
the  thigh.  This  pain  is  increased  by  exertion  of  any  sort,  and 
particularly  by  long  walks  or  rides.  The  pain  is  aggravated  by 
constipation  ;  and  it  is  often  increased  during  the  menstrual 
period.  Occasionally  paroxysmal  attacks  of  pain  come  on,  not 
unlike  nephritic  colic.  In  these  attacks  are  sometimes  found 
symptoms  of  blocking  of  the  renal  artery  or  ureter :  such  are, 
suppression  of  urine,  with  headache,  vomiting,  foul  tongue,  and 
other  symptoms  of  uraemia.  Transitory  attacks  of  hydronephro- 
sis may  be  caused  by  torsion  of  the  ureter.  Very  frequently 
there  is  considerable  intestinal  or  stomachic  disturbance,  shown 
by  dyspepsia,  flatulence,  colic,  sickness,  anorexia,  and  diarrhoea. 
In  a  few  cases  transient  attacks  of  jaundice  have  been  observed. 
Frequency  of  micturition  or  even  tenesmus  may  be  present. 
All  such  symptoms  are  relieved  by  lying  down.  Pyelitis  may 
show  itself  by  the  presence  of  pus  in  the  urine.     QEdema  of  one 


SYMPTOMS  OF  MOVABLE  KIDNEY.  509 

leg,*  and  jaundice  from  pressure  upon  the  common  duct,  f  have 
been  noted.  Those  symptoms  which  may  be  considered  as 
suggesting  renal  strangulation  are  found  associated  with  an 
increase  in  the  size  of  the  movable  tumour. 

The  objective  signs  are :  tumour  in  the  upper  abdomen,  of 
the  shape,  size,  and  consistence  of  a  normal  kidney,  which,  upon 
manipulation,  slips  away  from  the  examining  finger,  usually  in 
the  direction  of  its  proper  site  in  the  loin.  The  patient  will 
frequently  draw  attention  to  the  tumour,  and  will  explain  that 
it  changes  its  position.  By  comparison  of  the  two  loins,  a  want 
of  resistance  may  be  detected  by  the  grasping  fingers  on  the 
side  to  which  the  movable  tumour  tends  to  glide.  The  abdo- 
minal parietes  being  usually  lax,  this  sign  may  be  fairly  definite : 
the  laxity  may  be  so  great  that  the  tumour  may  be  bodily 
grasped  in  the  fingers,  replaced  in  the  loin,  and  there  palpated 
in  comparison  with  the  opposite  side.  When  handled  in  this 
way,  the  kidney  will  show  a  tendency  to  slip  away  from  its 
situation  in  the  loin ;  and  this  tendency  may  be  encouraged  by 
making  the  patient  turn  to  the  opposite  side  or  stand  upright. 
Its  range  of  mobility  is  characteristic.  Between  the  umbilicus 
and  the  side  of  the  abdomen  laterally,  and  between  the  ribs  and 
the  crest  of  the  ilium  vertically,  the  movable  kidney  may  be 
moved,  in  varying  degree,  almost  anywhere ;  but  beyond  the 
middle  line,  or  into  the  pelvis,  it  will  not  go.  The  renal  artery 
has  been  felt  pulsating  on  its  concave  inner  edge ;  but  this  is 
unusual. 

Percussion  gives  little  help.  As  intestine  overlies  the  tumour, 
the  note  may  be  of  normal  resonance,  or  but  slightly  muffled. 
Increased  resonance,  as  compared  with  the  opposite  side,  may 
be  present  in  the  loin. 

During  the  physical  examination,  a  subjective  s5miptom  of 
great  value  is  elicited.  This  is  a  peculiar  sickening  and  painful 
sensation,  analogous  to  that  experienced  during  compression  of 
the  testicle  in  man  or  the  ovary  in  woman. 

Diagnosis. — A    movable    kidney   may   be    confounded    with 

*  Giraud,  jfourn.  Hebd.  de  Progirs  des  Sc,  Med.,  1836,  vol.  iv.,  p.  445. 
t  Brit.  Med.  Jouvn,,  Jan.  29th,  1876. 


510  NEPHRORRAPHY. 

tumours  of  the  omentum,  the  ovary,  the  parovarium,  the  gall- 
bladder, and  the  pylorus.  It  may  be  mistaken  for  impacted 
faeces  in  the  colon.  I  have  removed  a  hydro-salpinx  which  was 
at  first  diagnosed  by  friends  and  by  myself  as  a  movable  kidney. 
A  growth  in  the  pancreas  I  have  knov/n  to  be  taken  for  mis- 
placed and  movable  kidney.  It  is  probably  not  necessary  to  do 
more  than  mention  the  fact  that  these  and  such  growths  may  be 
taken  for  movable  kidney. 

The  diagnosis  of  movable  from  floating  kidney  cannot  be 
worked  out  with  certainty.  Excessive  mobility  may  suggest  a 
floating  kidney :  but  it  is  just  as  likely  to  turn  out  to  be  a 
movable  kidney  with  a  wide  range  of  mobility.  Though  it  is 
practically  of  supreme  importance  that  we  should  be  able 
clinically  to  differentiate  the  one  from  the  other,  it  has  not  yet 
been  possible  to  do  so.  >. 

Indications  for  Operation. — Many  cases  of  movable  kidney 
require  no  treatment  beyond  a  properly  fitted  abdominal  sup- 
port. Others,  in  spite  of  such  support  and  of  other  palliative 
measures,  are  attended  with  great  discomfort,  or  serious  derange- 
ment of  health.  In  a  third  class  there  is  positive  danger  to  life. 
This  last  class  would  include  those  cases  in  which  there  is 
present,  along  with  the  mobility,  some  inflammatory  or  degener- 
ative condition,  such  as  has  already  been  described. 

The  indication  to  operate  is  the  urgency  of  the  case.  The 
operation  to  be  chosen  is  nephrorraphy.  Of  i8  cases  of  this 
operation  collected  by  Gross,*  one  died.  Newman  has  col- 
lected 5  more  cases,  all  successful.  To  these  a  second  operation 
of  my  own  may  be  added,  giving  a  total  of  24  with  one  death. 
The  operation  cannot  be  considered  as  free  from  danger.  It  is 
to  be  undertaken  only  after  a  full  and  fair  trial  of  all  known 
palliative  measures,  and  at  the  desire  of  the  patient. 

Nephrectomy   has   been    performed    at   least    30   times   for 

movable  kidney  (Newman).     Of  these,  21  recovered  and  9  died. 

For  simple  movable  kidney,  the  operation  is  to  be  condemned ; 

it  is  altogether  an  overdoing  of  surgical  proceeding.     But  not 

*  Internat.  Joum.  Med.  Sc,  July,  1885. 


THE   OPERATION.  511 

all  of  these  extracted  mobile  kidneys  were  healthy;  at  least  lo 
of  them  were  diseased.  Two  were  cystic,  2  contained  calculi ; 
these  4  recovered  :  of  the  others — i  containing  pus  and  cheesy 
material,  i  sarcomatous,  i  encephaloid,  i  fatty,  all  died. 
There  were  4  deaths  among  20  excisions  of  healthy  movable 
kidneys — a  mortality  of  20  per  cent.  It  need  scarcely  be  added, 
that  nothing  less  than  great  danger  to  life,  such  as  might  occur 
from  strangulation  or  diffuse  suppuration,  would  justify  the  in- 
currence of  such  a  grave  risk. 

In  the  case  of  floating  kidney,  when  nephrorraphy  may  be 
impossible,  the  negation  of  nephrectomy  need  not  be  so  emphatic. 
Still,  in  this  case,  only  failure  of  a  patient  and  skilful  attempt  at 
fixation,  and  the  continuation  of  grave  and  alarming  symptoms, 
would  justify  the  adoption  of  the  major  operation. 


THE    OPERATION. 

The  first  recorded  operation  was  performed  by  Dr.  E.  Hahn, 
of  Berlin,*  in  April,  1881,  and  he  gave  it  the  name  it  bears. 
He  exposed  the  capsule  of  the  kidney  by  an  incision  in  the  loin 
between  the  ilium  and  the  last  rib,  along  the  edge  of  the  sacro- 
lumbalis  muscle.  The  perinephric  fat  was  drawn  into  the 
wound,  and  sutured  to  muscle  and  fascia  by  half  a  dozen  catgut 
sutures.  Having  found  that  after  this  operation  the  kidney 
broke  loose,  he  recommended  a  more  thorough  proceeding  by 
placing  the  sutures  in  the  incised  capsule  proper,  and  fixing 
them  to  the  superficial  tissues. 

Many  variations  on  this  mode  of  operating  have  been 
described,  nearly  all  of  them  successful.  Carrying  the  sutures 
through  fat  alone,  through  both  fat  and  fibrous  capsule,  and 
through  fibrous  capsule  alone ;  simple  closure,  with  ordinary 
drainage ;  drainage  by  a  large  tube  laid  along  the  convex 
surface  (Newman),  so  as  to  get  a  considerable  growth  of  granu- 
lation tissue;  packing  of  the  wound  by  gauze  or  lint  (Morris), 
and  making  it  granulate  from  the  bottom,  have  all  been  brought 
forward  with  the  recommendation  of  success.  In  a  case  of 
*  Centralbl.  fur  Chir.,  July  23rd,  1881. 


512  NEPHRORRAPHY. 

mistaken  diagnosis,  where  I  opened  the  abdomen  and  found  a 
movable  kidney,  I  succeeded  in  fixing  it  by  scratching  its 
capsule  freely  with  a  needle,  while  the  hand  inside  the  abdomen 
pressed  it  against  the  loin.  Whatever  detail  in  operating  may 
be  favoured,  there  is  no  doubt  that  the  best  plan  of  fixation  is  by 
extra-peritoneal  incision  through  the  lumbar  muscles. 

The  best  incision  is  an  oblique  one,  as  recommended  by 
Bryant  for  lumbar  colotomy.  More  accurately,  it  may  be 
described  as  being  parallel  to  the  colotomy  incision,  an  inch 
or  less  behind  it,  and  rising  to  the  same  height  under  the  ribs. 
As  this  lumbo-renal  incision  will  have  to  be  frequently  referred 
to,  and  as  it  is  here  performed  under  conditions  most  nearly 
approaching  the  normal,  it  may  now  be  fully  described. 

The  patient  is  placed  on  the  side,  resting  on  a  hard  round 
pillow,  so  as  to  increase  to  its  utmost  limits  the  costo-iliac  space 
on  the  side  of  operation.  The  twelfth  rib  is  located  both  by 
palpation  and  by  counting.  The  top  of  the  incision  is  fixed 
upon,  at  least  half  an  inch  below  the  last  rib,  and  close  to  the 
outer  border  of  the  erector  spinae.  It  is  continued  downwards 
and  forwards  towards  the  crest  of  the  ilium  in  a  direction  which 
the  eye  will  suggest  as  the  most  convenient,  according  to  the 
conformation  of  the  body  of  the  patient.  The  length  ought  not 
to  be  less  than  three  inches.  As  the  size  and  the  shape  of  the 
ilio-costal  interval  vary  greatly  in  different  individuals,  a  fixed 
and  definite  line  for  the  continuation  of  the  incision  cannot 
be  laid  down.  Only  the  beginning  of  the  incision  can  be 
fixed. 

After  dividing  the  skin  and  fat,  the  superficial  fascia  is 
exposed.  A  few  cutaneous  branches  from  the  lumbar  and  the 
inter-costal  arteries  will  be  divided,  and  may  require  forci-pres- 
sure.  The  fascia  being  divided  by  the  knife  to  the  extent  of  the 
skin  wound,  the  outer  edge  of  the  latissimus  dorsi  and  the  pos- 
terior border  of  the  external  oblique  will  be  exposed.  At  this  stage 
of  the  operation,  I  think  it  is  best  to  lay  the  knife  aside,  and 
perform  all  further  dissection  by  means  of  bent  scissors.  The 
latissimus  dorsi  being  divided  by  cutting  upwards  and  the 
external  oblique  by  cutting  downwards,  the  internal  oblique  and 


THE  OPERATION.  513 

the  transversalis  will  now  be  laid  bare.  The  edge  of  the  erector 
spinae,  to  which  is  attached  the  fascia  lumborum,  need  not  be 
divided.  The  internal  oblique  and  the  transversalis  aponeurosis 
are  divided  upwards  and  downwards  by  the  scissors.  Here 
branches  of  the  lumbar  arteries  may  be  divided,  and  require 
forci-pressure.  The  outer  margin  of  the  quadratus  lumborum  is 
now  exposed.  The  breadth  of  this  muscle,  and  consequently 
the  extent  to  which  it  encroaches  upon  the  field  of  operation,  is 
very  variable.  If  it  cannot  be  retracted,  the  encroaching  fibres 
ought  to  be  divided  by  a  stroke  of  the  scissors.  Finally,  the 
deep  layer  of  the  lumbar  aponeurosis,  often  a  dense  and  well- 
marked  structure,  is  divided  from  end  to  end  of  the  incision. 
This  exposes  the  circumrenal  fat,  which  probably  bulges  into 
the  wound. 

The  dissection  will  have  been  aided  by  the  use  of  broad 
retractors  in  the  hands  of  an  assistant.  The  retractors  are  now 
made  to  gather  up  the  whole  of  the  divided  tissues  down  to  the 
fatty  capsule,  and  the  opening  is  stretched  to  its  utmost  dimen- 
sions. A  second  assistant  pushes  upwards  and  backwards  the 
pendulous  abdomen,  and  specially  seeks  to  force  the  kidney 
towards  the  lumber  incision. 

Two  fingers,  carried  around  the  kidney  and  its  capsule,  now 
seek  to  diagnose  the  exact  nature  of  the  conditions  associated 
with  the  mobility.  If  it  is  clear  that  the  fatty  tunic  is  closely 
adherent  to  the  fibrous  capsule,  the  former  need  not  be  opened. 
But  if  the  kidney  has  space  for  movement  inside  its  fatty  capsule, 
then  this  ought  to  be  widely  opened  along  the  renal  border,  and 
the  finger,  inserted  through  this  opening,  moved  freely  over  the 
renal  surface,  so  as  to  excite  plastic  inflammation.  In  every 
case  of  doubt  as  to  the  exact  nature  of  the  mobility — and  most 
cases  will  be  doubtful — the  free  border  of  the  kidney  will  be 
exposed  by  division  of  the  fatty  capsule.  Aseptic  irritation, 
such  as  would  be  produced  by  the  exploring  finger,  is  not  only 
not  harmful,  but  positively  beneficial,  as  setting  up  an  inflam- 
mation which  may  result  in  plastic  adhesion.  To  facilitate  cure 
as  well  as  diagnosis,  most  surgeons  would  expose  the  free  border 
of  the  kidney  by  division  of  the  surrounding  fat. 

34 


514  NEPHRORRAPHY 

Fixation  of  the  kidney  is  secured  by  means  of  catgut,  or 
perhaps  better,  by  silk-worm  gut  sutures  carried  through  its 
fibrous  capsule  and  the  margins  of  the  incision.  Local  irri- 
tation, with  drainage,  is  attained  by  means  of  a  large  rubber 
tube  placed  along  the  kidney  border,  and  doubled  on  itself  at 
the  extremities  of  the  wound ;  the  two  ends  being  brought  out 
through  the  incision.  This  piece  of  tubing  is  not  to  be  removed 
till  evidences  of  inflammation  appear. 

Newman  found,  in  a  case  upon  which  he  successfully 
operated,  that  catgut  sutures  became  absorbed  where  they 
passed  through  renal  tissue  proper  more  quickly  than  anywhere 
else.  Superficial  stitches  through  the  fibrous  capsule  would 
be  quite  efficient,  and  the  chances  of  premature  absorption 
are  less.  Morris,  in  his  most  recent  operation,  has  carried 
several  sutures  through  the  renal  tissues,  and  fixed  them  over 
the  lumbar  wound. 

It  is  probable  that  permanency  of  cure  would  be  more 
certainly  secured  by  general  adhesions  all  around  the  kidney, 
or  by  inflammatory  condensation  of  its  fatty  surroundings,  than 
by  the  temporary  and  local  adhesion  produced  by  sutures. 
Sutures  are  co-aptating,  rather  than  uniting :  they  keep  the 
tissues  in  contact  while  they  may  adhere ;  they  only  to  a  slight 
extent  promote  and  secure  adhesion.  To  the  end  of  permanent 
fixation,  I  should  lay  much  stress  on  the  stirring  up  of  circum- 
renal  fat  by  finger  or  blunt  instrument. 

The  closure  of  the  wound  and  the  after-tratment  require  no 
special  description. 


Nephrolithotomy. 

By  Nephro-lithotomy  is  meant  the  removal  by  surgical 
operation  of  a  stone  situated  in  the  substance  or  the  calyces  or 
the  pelvis  of  the  kidney.  No  better  definition  of  the  operation 
can  be  given  than  that  of  M.  Hevin,*  enunciated  a  hundred  and 
thirty  years  ago  :  "  La  Nephrotomie,  ou  plutot,  suivant  Schur- 
rigius,  la  Nephro-lithotomie,  est  I'operation  par  laquelle  on 
extrait  une  ou  plusieurs  pierres  au  moyen  d'une  incision  qu'on 
fait  a  la  region  lombaire,  et  qui  penetre  jusques  dans  la  cavite  du 
bassinet  du  rein." 

History. — Up  to  a  very  recent  date,  all  operations  upon  the 
kidney  were  performed  for  stone  :  nephrotomy  was  practically 
synonymous  with  nephro-lithotomy.  But,  in  most,  if  not  in  all, 
cases  of  ancient  operation,  cutting  for  stone  in  the  kidney  was 
as  much  the  evacuation  of  an  abscess,  as  the  extraction  of  a 
foreign  body.  Hippocrates  himself  recommends  incision  for  the 
removal  of  renal  calculus,  "should  the  parts  swell  and  become 
elevated;"  that  is,  if  there  is  an  abscess  pointing.  Neither 
Celsus  nor  Galen  refer  to  the  operation ;  so  that  we  may  con- 
clude that  it  had  not  an  assured  position  among  the  ancients. 
Arabian  authors  have  casually  referred  to  it.  Turner,  in  his 
Art  of  Surgery,  published  in  London  in  1727,  quotes  various 
writers  to  show  that  surgeons  in  very  early  times  were  familiar 
with  lumbar  nephrotomy.  Avicen  f  says  :  "There  are  some  who 
attempt  to  take  the  stone  out  of  the  kidneys  by  incision  of  the 
Ilea,  but  there  is  great  danger  therein."  Cardan,  lamenting 
over  the  number  of  lost  operations  that  were  common  in  the 
days  of  Hippocrates,  mentions,  among  others,  this  one  of 
removal  of  stones  from  the  kidney.  He  quotes  AlbertusJ  as 
having  met  with  a  case  where  eighteen  stones  were  removed 
from  the  loin  of  a  woman  who  was  long  affected  with  nephritic 
illness.     Caspar  Bauhin  reports  the  case  of  a  girl  who  had  an 

*  Mem.  Acad.  Roy.,  Sec,  torn,  iii.,  p.  238.     Paris,  1757. 

t  Canon.,  lib.  iii.       J  De  Varietat.  lib.  viii.,  cap.  44, 

34  * 


516  NEPHRO-LITHOTOMY. 

induration  and  swelling  in  the  loin,  from  which  a  surgeon,  after 
incision,  removed  two  stones. 

All  these  were  probably  cases  of  evacuation  of  an  abscess, 
caused  by  stone ;  certainly  none  of  them  were  operations  per- 
formed upon  a  kidney  approximately  healthy.  The  first  case  in 
which  an  operation  is  supposed  to  have  been  performed  for  the 
removal  of  stone  from  a  kidney  that  was  not  suppurating  is 
related  by  Mezerai,  in  his  Abrege  Chronologiqtie  de  I'Histoire  du 
France.  The  doctors,  says  the  historian,  having  learned  that  a 
certain  archer  of  Meudon  or  Bagnolet,  who  had  long  been 
afflicted  with  stone  in  the  kidney,  had  been  condemned  to  death 
for  his  crimes,  requested  the  magistrates  to  hand  him  over  to 
them  that  they  might  experiment  and  see  if  it  were  practicable 
to  extract  the  stone  without  killing  him.  The  experiment  was 
successful,  and  the  man  is  said  to  have  lived  for  several  years  in 
excellent  health.  This  occurred  about  1680.  Pare,  Sabatier, 
and  others  discredit  this  operation ;  and  we  can  scarcely  give 
full  credence  to  it.  The  mere  record  of  it,  however,  shows  that 
it  was  in  men's  minds,  and  regarded  as  within  the  bounds  of 
possibility.  Fare's  unbelief  or  disapproval,  it  must  be  noted,  is 
by  no  means  disproof  or  condemnation :  great  as  he  was,  he 
disbelieved  in,  or  disapproved  of,  more  than  one  operation 
which  was  both  possible  and  sound. 

The  second  case  was  the  well-known  one  of  Mr.  Hobson, 
the  English  Consul  at  Venice,  recorded  in  the  Philosophical 
Transactions  for  1696  by  Dr.  Bernard,  to  whom  Mr.  Hobson 
related  his  experiences  ten  years  after  operation.  Some  dis- 
credit has  been  cast  upon  this  case  also  ;  but  I  think  there  can 
be  no  reasonable  doubt  that  the  operation  was  performed, 
though  it  is  just  possible  that  suppuration  existed.  The  case, 
related  by  the  patient  himself,  who  was  not  a  medical  man,  is 
too  circumstantial  to  be  purely  fictitious.  The  scholarly  and 
accurate  M.  Hevin,*  in  his  historical  and  critical  researches 
into  Nephrotomy,  says  that  he  saw  and  examined  the  fistula  in 
Mr.  Hobson's  side,  and  fully  satisfied  himself  as  to  the  reality 
of  the  operation.  In  Hevin's  paper  is  given  a  full  account  of 
*  Mem.  Acad.  Roy.,  &c.,  torn,  iii.,  p.  238,  1757. 


HISTORY.  517 

the  life  and  work  of  the  Marchettis  of  Milan,  one  of  whom  per- 
formed the  operation.  I  have  elsewhere  quoted  my  opinion  as 
to  the  reality  of  this  operation  ;  and  Downes  has  contributed 
an  able  article  to  the  same  purpose. 

The  same  amount  of  credence  cannot  be  accorded  to  the 
case  related  by  Joachim  Camerarius,*  in  which  a  surgeon,  at 
the  urgent  request  of  a  nobleman  who  was  suffering  agonies, 
successfully  extracted  a  stone  that  was  plugging  one  of  the 
ureters.  Schurrigius,f  using  the  case  of  a  certain  General  de 
Birckholtz  as  a  text,  fully  discusses  the  whole  question  under 
the  name  Nephro-lithotomy.  In  his  case  he  would  not  operate, 
because  he  thought  that  the  stones  were  blocking  the  ureter  too 
low  down  to  be  within  reach. 

The  practical  outcome  of  these  and  other  cases  is  fittingly 
summarised  by  M.  Lafitte,  in  the  second  volume  of  the  Memoivs 
of  the  Royal  Academy  of  Surgery.  He  concludes  that  nephro- 
lithotomy is  not  to  be  reckoned  as  a  justifiable  surgical  pro- 
ceeding until  abscess  has  formed.  Rousselet  and  Riolan  would 
remove  a  stone  that  could  be  felt.  Nearly  all  subsequent  writers 
admit  the  propriety  of  removing  stones,  provided  abscess  has 
formed  ;  and  there  is  almost  equal  unanimity  in  condemning  the 
operation  in  the  absence  of  abscess.  In  the  first  volume  of 
Medical  Essays  and  Observations,  published  in  Edinburgh  in  1752 
(p.  186),  Mr.  John  Douglas  relates  how  he  attempted,  after 
death,  to  see  whether  it  was  possible  to  remove  a  stone  that  had 
been  diagnosed  to  exist  during  life.  He  found  that  it  was  im- 
possible. The  depth  of  the  incision  was  three  and  a  half 
inches ;  and  at  this  distance  from  the  surface  he  found  it 
impossible  to  reach  the  kidney  substance.  Such  a  record  lends 
weight  to  the  opinion  that  surgery,  in  some  of  its  departments, 
has  done  nothing  but  retrograde  for  more  than  a  thousand 
years ;  and  that,  in  the  last  fifty  years,  we  have  done  little  more 
than  pick  up  the  clues  that  were  lost  when  the  Alexandrian 
Library  was  burnt. 

There  is  no  doubt  that  surgery  is  indebted  to  Mr.  Henry 
Morris,  of  Middlesex  Hospital,  for  the  invention  of  the  modern 
*  Schenck,  Observ.  Med.,  lib.  iii.       f  Liikolog.  Hist.  Med.,  cap.  13. 


518  NEPHRO-LITHOTOMY. 

operation  of  nephro-lithotomy.  He  performed  his  first  operation 
in  1880.  Some  hundreds  of  operations  have  been  performed 
since  then ;  but  the  operation  of  to-day  practically  continues 
as  Mr.  Morris  left  it. 


RENAL    CALCULUS. 

Pathological  Anatomy. — Renal  calculus  occurs  chiefly  before 
the  age  of  fifteen  and  after  fifty.  According  to  Mr.  Thomas 
Ta3dor,  quoted  by  Morris,  each  age  has  ics  variety  of  calculus : 
"  The  nucleus  of  renal  calculi  formed  in  infancy  is  urate  of 
ammonia ;  the  nucleus  of  calculi  formed  in  adult  life  is  uric 
acid ;  whereas  that  of  calculi  formed  after  the  fortieth  year  is 
oxalate  of  lime."  Whatever  its  nature,  and  wherever  it  origi- 
nates, the  calculus  usually  arises  to  pathological  and  clinical 
importance  in  a  calyx,  or  in  the  pelvis,  or  in  the  upper  extremity 
of  the  ureter.  One  or  both  kidneys  may  be  affected  with 
lithiasis ;  and  one  or  more  stones  may  be  found.  The  amount 
of  mischief  set  up  varies  according  to  the  size  of  the  stone,  the 
roughness  or  smoothness  of  its  surface,  and  the  position  it 
occupies.  A  very  rough  stone,  as  one  of  oxalate  of  lime,  may 
lie  quietly  in  a  calyx  for  years ;  while  a  small  rounded  smooth 
stone,  which  has  not  escaped  from  the  secreting  substance,  may 
set  up  inflammation  or  suppuration.  A  small  stone  in  the  pelvis 
which  just  fits  the  orifice  of  the  ureter  may,  by  preventing  the 
outflow  of  urine,  cause  most  mischief  of  all. 

Three  types  of  nephro-lithiasis  may  be  pathologically  differ- 
entiated. The  first  is  the  small  stone,  with  healthy  renal  tissue. 
Tlie  second  is  the  large,  perhaps  branched,  stone,  coated  with 
phosphates,  and  lying  in  an  abscess-sac  the  walls  of  which  are 
the  thickened  and  suppurating  calyces.  The  third  is  the  small 
movable  stone,  blocking  the  ureteric  orifice,  and  causing  hydro- 
and  pyo-nephrosis,  with  destruction  of  renal  tissue.  Each  type 
has  its  special  clinical  features ;  and  for  each  a  variation  in  the 
operative  procedure  is  called  for.  Strictly  speaking,  these  types 
are  different  stages  or  casual  developments  of  the  same  disease; 
but  they  are  sufficiently  marked  to  be  worthy  of  differentiation. 


PATHOLOGICAL   ANATOMY.  519 

(i)  Gravel  formed  in  the  uriniferous  tubules  may  either  pass 
away  in  the  current  of  urine  without  causing  symptoms ;  or 
may,  after  increasing  in  size,  be  passed  with  difficulty  along 
the  ureter,  producing  symptoms  of  renal  colic ;  or  may  remain 
embedded  in  the  renal  tissue,  or  imprisoned  in  a  calyx.  Here 
it  may  remain  for  long  periods,  setting  up  symptoms  indica- 
tive of  irritation  rather  than  of  inflammation,  or  pathological 
degeneration.  Physically,  it  may  cause  bleeding,  and  set  up 
attacks  of  renal  congestion  or  inflammation,  which  spontaneously 
subside ;  physiologically,  it  begets  a  long  train  of  symptoms, 
referable  chiefly  to  the  influence  of  nerve  connection. 

(2)  In  the  calyces  or  the  pelvis,  a  stone  may  set  up  catarrh 
or  inflammation  of  the  lining  membrane,  with  secretion  of  pus, 
which  passes  into  the  bladder  with  the  urine.  As  the  stone 
grows  the  calyces  are  dilated,  while  their  walls  are  thickened ; 
accretion  takes  place  in  the  areas  where  pressure  is  least,  and 
the  stone  thus  comes  to  be  a  cast  of  the  dilated  calyces  which  it 
occupies.  The  stream  of  urine  flows  along  between  the  stone 
and  the  encircling  sac ;  there  is  no  urinary  obstruction ;  and 
renal  tissue  is  destroyed  by  continued  suppurative  inflammation, 
set  up  by  the  foreign  body.  In  this  way  a  renal  calculus  may 
attain  to  enormous  dimensions,  without  causing  marked  symp- 
toms. In  the  museum  of  the  Bristol  Infirmary  is  an  enormous 
stone,  which  is  a  perfect  cast  of  the  calyces  and  lobules  of  a 
kidney  enlarged  to  four  times  its  normal  dimensions :  this  stone 
was  accidentally  discovered  at  the  post-mortem  examination  of 
a  patient  who  died  of  lung  inflammation,  and  who  had  presented 
no  sign  of  renal  calculus.  Sometimes  the  calculus  rolls  about 
in  an  abscess  sac  of  its  own  formation,  and  increases  in  size  in 
the  pelvis  or  calyces  in  the  same  manner  as  a  vesical  calculus. 
Suppurative  inflammation  spreads  by  continuity  of  tissue  to  the 
renal  substance,  and  will  ultimately  cause  its  complete  destruc- 
tion. The  further  course  of  this  process  is  towards  the  forma- 
tion of  peri-nephric  abscess,  which  may  burst  through  the  loin, 
forming  urinary  fistula. 

(3)  When  a  comparatively  small  stone  rolling  about  in  the 
pelvis  becomes  engaged  in  the  orifice  of  the  ureter,  acting  as  a 


520  NEPHRO-LITHOTOMY. 

sort  of  ball-valve,  the  outflow  of  urine  is  checked,  and,  in 
addition  to  calculus  pyelitis,  there  is  set  up  an  atrophic 
degeneration  of  the  kidney,  which  may  ultimately  leave  it  as 
a  loculated  sac,  containing  very  little  healthy  secreting  sub- 
stance. In  the  fully  developed  condition,  numerous  cavities 
are  found  containing  brown  putrid  urine,  with  numerous 
calculi ;  and  in  the  bottom  of  the  pelvis,  or  lying  in  the  orifice 
of  the  ureter,  is  found  one  stone  which  is  presumably  the  source 
of  the  mischief.  The  renal  tissue  is  not  destroyed  by  advancing 
suppurative  inflammation,  but  by  compression  and  distension, 
brought  on  by  obstruction  to  the  flow  of  urine.* 

Many  varieties  of  calculus  are  formed  in  the  kidney.  The 
most  common  is  uric  acid ;  next  in  frequency  comes  oxalate  of 
lime.  Other  varieties  are  composed  of  phosphate  of  lime,  car- 
bonate of  lime,  the  triple  phosphate,  urate  of  ammonia,  cystine, 
and  xanthine.  Occasionally  the  nucleus  is  formed  of  a  blood- 
clot,  or  a  fibrinous  coagulum.  Indigo  has  been  found  in  the 
centre  of  a  renal  calculus ;  the  uro-stealith,  or  "  soap-stone,"  is 
very  rare. 

Symptoms  and  Diagnosis. — Both  kidneys  are  about  equally 
liable  to  calculus ;  in  about  a  fifth  of  the  cases,  stone  exists 
simultaneously  in  both  organs.  It  is  more  common  in  males 
than  in  females,  and  is  most  frequently  found  to  arise  before 
middle  age. 

A  stone  in  the  kidney  will  probably  first  signify  its  presence 
by  pain  and  haemorrhage.  Sometimes  the  symptoms  are  slight 
and  transient ;  frequently  they  are  exceedingly  severe  and  per- 
sistent, so  much  so  as  almost  to  make  life  unbearable.  Other 
symptoms  associated  with  the  pain  and  haematuria  are  gastric 
disturbances,  retraction  of  the  testes,  irritability  of  the  bladder, 
pus  in  the  urine,  and  sometimes  suppression  of  urine. 

The  pain  is  usually  felt  in  the  loin,  over  the  kidney  affected ; 
though  it  may  be  felt  in  both  loins,  while  one  kidney  is  healthy. 

*  Jordan  Lloyd  (Practitioner,  Sept.,  1887)  has  brought  his  extensive  expe- 
rience and  study  to  bear  on  the  further  elaboration  of  these  types,  mainly 
from  the  clinical  and  practical  standpoints.  To  his  paper  I  would  refer  my 
readers. 


SYMPTOMS.  521 

It  is  of  a  dull,  heavy,  dragging  character,  and  may  shoot  down- 
wards along  the  course  of  the  ureter,  and  be  referred  to  the 
testicle  or  even  to  the  point  of  the  penis.  Sometimes  it  may 
shoot  down  the  thigh,  and  be  specially  referred  to  the  leg,  the 
sole  of  the  foot,  or  even  the  knee.  Apart  from  the  actual  pain, 
there  is  sometimes  a  curious  feeling  of  consciousness  in  the 
patient's  mind  as  to  the  existence  of  a  stone  in  the  kidney. 
Some  tenderness  on  pressure  over  the  affected  kidney  is  usually 
confessed  to.  The  pain  is  intermittent,  and  is  usually  at  its 
worst  after  active  or  jerking  movements.  Posture  may  affect  it. 
Thus,  a  patient  who  suffers  while  sitting  may  be  relieved  by 
walking  or  lying  down ;  pain  which  may  be  severe  while  the 
patient  lies  on  one  side,  may  be  relieved  by  his  turning  on  to 
the  other ;  and  various  other  positions,  known  from  experience, 
may  afford  comfort. 

Symptoms  referred  to  the  testicle  of  the  diseased  side,  when 
they  exist,  are  characteristic  and  valuable.  Peculiar  sensations, 
varying  from  tenderness  to  actual  pain  of  a  neuralgic  character; 
some  degree  of  swelling,  and  retraction  of  it  within  the  scrotum, 
are  the  most  common  concomitants  of  calculus.  In  the  female 
such  pain  may  be  referred  to  the  labium,  or  the  orifice  of  the 
urethra. 

Symptoms  derived  from  the  bladder  and  urine  are  common. 
Vesical  irritation  is  a  common  symptom  of  renal  calculus.  In 
fact,  so  common  is  it,  that  patients  under  close  observation  are 
usually  sounded  for  stone  before  the  diagnosis  of  renal  calculus 
is  made.  There  will  be  a  constant  desire  to  pass  water,  with 
frequent  passing  of  it.  Haematuria,  remittent  and  not  very 
profuse,  is  very  frequently  associated  with  the  complaint. 
Occasionally  it  is  absent  throughout  the  disease.  Sometimes 
it  is  present  only  after  exercise  ;  if  it  exists  at  other  times, 
jarring  motion  is  almost  certain  to  aggravate  it.  As  found  in 
the  urine,  the  blood  is  mixed  less  intimately  than  it  is  in  other 
diseases  of  the  kidney,  and  more  intimately  than  in  disease  of 
the  bladder  or  prostate.  Casts  of  the  ureter  are  occasionally 
found,  and  sometimes  small  rounded  clots.  Pus  may  be  found 
in  the  urine  from  pyelitis  that  may  have  been  set  up.     A  pro- 


522  NEPHEO-LITHOTOMY. 

bable  guess  as  to  the  nature  of  the  stone,  its  roughness  or 
smoothness,  may  be  made  from  the  amount  of  the  bleeding. 

Symptoms  referable  to  the  stomach  are  not  uncommon. 
There  may  be  nausea,  vomiting,  and  irregular  attacks  of  indi- 
gestion, accompanied  with  flatulence  and  colicky  pains. 

A  presumptive  evidence  of  stone  in  the  kidney  is  a  previous 
history  of  renal  colic,  arising  from  the  passage  of  stone  along 
the  ureter.  If  the  kidney  has  formed  a  stone  once,  it  may  do  so 
again.  Such  an  attack  once  borne,  is  a  memory  for  a  lifetime. 
The  acute  agony  of  pain  in  the  loins,  shooting  down  the  ureter 
into  the  testicle  ;  the  depressing  nausea  and  ineffectual  vomiting; 
the  persistent  vesical  tenesmus,  and  the  final  exacerbation  as  the 
stone  passes  the  narrowed  channel  before  entering  the  bladder, 
make  up  a  combination  of  suffering  as  intense,  perhaps,  as 
disease  can  create.  If  renal  colic  has  existed,  the  patient  is 
sure  to  know  of  it. 

A  stone  has  actually  been  felt  in  the  kidney  by  the  examin- 
ing finger,  and  a  sensation  of  grating  has  been  communicated 
by  the  rubbing  of  several  stones  together.  But  such  an  aid  to 
diagnosis  is  very  rarely  afforded.  Strong  pressure  or  a  sharp 
squeeze,  as  causing  an  increase  of  pain  of  a  pricking  or  stabbing 
character,  may  be  of  great  diagnostic  value. 

As  a  result  of  extensive  and  carefully  elaborated  clincal 
experience,  Bennett  May*  groups  cases  of  stone  in  the  kidney 
into  three  classes :  (i)  Where  pain  is  the  only  prominent  symp- 
tom— that  is,  where  no  help  is  given  to  the  diagnosis  by  the 
physical  examination  of  the  urine  or  the  patient,  though  consti- 
tutional symptoms  may  be  present.  (2)  Where  pus  or  blood, 
or  both,  are  found  in  the  urine.  (3)  Where,  in  addition  to  any 
of  the  above,  there  is  a  lumbar  swelling  or  tumour  in  the  region 
of  the  kidney.  This,  it  will  be  seen,  runs  in  some  respects 
parallel  with  the  division  given  above  from  the  pathological 
point  of  view.  In  women,  according  to  this  authority,  haema- 
turia  may  be  more  misleading  as  a  symptom  of  stone  in  the 
kidney  than  in  men ;  a  peculiarity  which  may  depend  on  the 
fact,  pointed  out  by  Lloyd,  that  in  women  the  primary  and 
*  Birm.  Med.  Rev.,  Jan.,  1887. 


DIAGNOSIS.  523 

secondary  tubes  are  long  and  narrow,  and  therefore  more  likely 
to  closely  encircle  the  stone. 

An  element  of  confusion  arises  in  the  fact,  first  noted  by 
Thornton  and  confirmed  by  others,  that  stone  on  one  side  may 
produce  symptoms  on  the  other.  Godlee*  relates  a  very  inter- 
esting case  where,  after  a  stone  had  been  removed  from  the  right 
kidney,  there  was  severe  colicky  pain  on  the  left  side,  followed 
by  the  discharge  of  several  small  fragments  of  stone. 

The  differential  diagnosis  has  to  be  made  with  malignant 
and  villous  growths  of  the  bladder  ;  purpura  and  haemophilia  ; 
and  malignant  or  inflammatory  disease  of  the  substance  of  the 
kidney.  In  addition  to  the  symptoms  already  detailed,  the  pro- 
fuse haemorrhage  of  the  first,  with  abundant  clots  and  imperfect 
commingling  of  blood  and  urine,  will  help  us.  For  the  rest,  the 
existence  of  the  characteristic  dyscrasiae,  and,  in  the  case  of 
tumours,  the  presence  of  a  swelling  in  the  renal  region,  will  help 
us.  Haematinuria  will  be  recognised  by  its  characteristic  symp- 
toms, borne  out  by  a  microscopic  examination  of  the  urine. 
The  condition  most  likely  to  be  mistaken  for  renal  calculus  is 
early  strumous  disease  of  the  kidney.  The. presence  of  pain  in 
calculus,  and  the  absence  of  haematuria  in  strumous  disease, 
are  the  chief  signs  relied  upon  for  diagnosis.  I  have  on  two 
occasions  (once  with  the  assistance  of  my  colleague.  Dr. 
Shingleton  Smith)  diagnosed  strumous  kidney  from  the  dis- 
covery of  tubercle-bacilli  in  the  urine. 

An  attempt  to  diagnose  the  actual  pathological  condition 
present  ought  to  be  made. 

The  small  calculus  with  healthy  kidney  may  be  suspected 
when  the  symptoms  are  chiefly  or  entirely  haematuria  and  pain. 

The  large  calculus  embedded  in  an  abscess  sac  is  suggested 
by  pus  in  the  urine,  a  tumour  or  increased  resistance  in  the  loin, 
and  pain  on  pressure. 

The  hydro-nephrotic  kidney,  with  small  calculus  blocking  the 
ureter,  is  suggested  by  repeated  attacks  of  lumbar  pain,  alkaline 
or  putrid  urine  containing  little  pus,  and  a  swelling  in  the  loin, 
which  is  not  very  hard,  and  not  very  painful  on  being  pressed. 
*  Practitioner,  Oct.,  1887. 


524  NEPHRO-LITHOTOMY. 

Indications  for  Operation. — Dickinson  tells  us,  that  of  three 
individuals  who  have  stone  in  the  kidney,  only  one  dies  of  it ; 
the  other  two  die  of  something  else.  The  mere  presence  of 
stone  in  the  kidney  is  not,  therefore,  an  indication  for  operation. 
We  must,  in  the  first  place,  wait  to  see  if  the  stone  will  be 
passed  by  the  ureter :  and,  in  the  second  place,  come  to  a  deci- 
sion, either  that  the  calculus  is  setting  up  mischief  in  the  kidney 
which  may  endanger  life,  or  that  the  subjective  symptoms  are  so 
urgent  that  necessary  work  cannot  be  performed  or  health  is 
being  undermined.  In  every  case,  palliative  treatment  by  rest, 
the  exhibition  of  alkaline  drugs,  and  careful  dietary,  will  have 
been  fully  and  fairly  tried.  Morris  makes  the  wise  suggestion 
that,  when  anuria  follows  symptoms  of  calculus  in  one  or  both 
kidneys,  the  kidney  which  has  last  become  affected  should  be 
first  explored. 

A  further  reason  for  caution  in  proceeding  to  operate  is 
the  fact,  that  no  fewer  than  twenty-five  exploratory  operations 
have  been  performed,  and  no  stone  found.  This,  of  course, 
is  no  reproach  to  the  operation  itself;  on  the  contrary,  as 
all  the  patients  recovered,  it  speaks  in  its  favour.  This  more 
especially  refers  to  operation  where  the  kidney  is  comparatively 
healthy. 

Where  the  kidney  is  diseased,  the  indication  is  to  operate  at 
once,  provided  the  other  kidney  is  diagnosed  as  healthy.  In 
such  a  case,  the  operation  may  be  little  more  than  a  simple 
nephrotomy,  with  drainage  of  an  abscess.  If  advanced  suppu- 
ration exists,  the  question  of  nephrectomy  will  arise,  and  must 
be  decided  on  the  same  principles  as  would  guide  us  in  operating 
where  there  was  no  stone.  In  many  cases  of  suppurative  nephri- 
tis, stones  are  found  which  may  have  little  connection  with  the 
origin  of  the  disease.  Barker  points  out  that,  in  advanced 
calculous  disease,  both  nephro-lithotomy  and  nephrectomy  are 
about  equally  dangerous,  as  the  patients  are  usually  advanced 
in  years  and  much  pulled  down  in  strength.  Nephro-lithotomy, 
where  the  kidney  is  healthy,  is  a  very  safe  operation  :  as  yet,  its 
mortality  has  not  exceeded  lo  per  cent.  Of  21  operations  col- 
lected by  Gross,  2  died — a  mortality  of  9.52  per  cent.     Newmari 


THE  OPERATION.  525 

has  collected  42  operations  on  healthy  kidneys  without  a  death. 
He  finds  that  Brodeur  (possibly  Gross  also)  included  cases  in 
which  suppuration  existed.  Where  suppuration  was  present, 
60  operations  were  followed  by  26  deaths — a  mortality  of  43.3 
per  cent. 

THE    OPERATION. 

The  instruments  necessary,  besides  knife,  scissors  and  catch- 
forceps,  are  :  two  large  broad  retractors ;  a  fine  conical  needle, 
two  and  a  half  inches  long,  set  in  a  handle,  for  exploring  the 
kidney ;  and  specially-designed  sounds,  probes,  scoops,  or 
forceps,  for  detecting  the  stone  and  removing  it.  Lucas's  in- 
struments seem  to  be  admirably  suited  for  this  operation.  An 
ordinary  bladder-sound  with  short  beak  and  of  smallest  size  for 
children,  will  be  found  necessary,  if  the  kidney  is  to  be  explored 
in  the  manner  recommended  by  Jordan  Lloyd. 

The  best  incision  is  the  oblique  lumbar  one  recommended 
for  nephrorraphy.  Morris  favours  this  incision  :  Howse  made 
use  of  a  vertical  incision,  supplemented  by  a  transverse  one ; 
and  other  surgeons  have  variously  modified  it.  The  knife  is 
entered  close  to  the  edge  of  the  erector  spinge,  half  an  inch  or 
more  from  the  lower  border  of  the  twelfth  rib,  and  carried 
obliquely  downwards  and  forwards  towards  the  crest  of  the 
ilium  for  three  or  four  inches,  according  to  the  size  and  shape 
of  the  costo-iliac  space.  If,  in  spite  of  the  artificial  enlarge- 
ment of  the  costo-iliac  space  by  the  pillow  placed  under  the 
opposite  loin,  the  area  for  operation  is  very  limited,  the  incision 
may  be  curved  forwards,  after  being  carried  farther  back  than 
usual.  Additional  space  may  be  got  by  dividing  transversely 
the  fibres  of  the  quadratus  lumborum.  With  the  division  of 
the  deep  lumbar  aponeurosis  and  the  exposure  of  the  circum- 
renal  fat,  this  preliminary  stage  of  the  operation  is  finished.  All 
pressure  forceps  are  now  removed,  vessels  of  considerable  size 
being  ligatured,  and  the  wound  is  made  to  gape  as  much  as 
possible  by  retractors  in  the  hands  of  an  assistant. 

The  fatty  capsule  is  teased  open  with  forceps,  and  the  kidney 
surface  is  exposed.    Morris  says  that,  as  the  back  of  the  kidney 


526 


NEPHRO-LITHOTOM  Y. 


is  approached,  there  may  be  noted  differences  in  the  character, 
of  the  fat  ;  that  next  the  kidney  being  of  fine  texture,  and  of  a 
delicate  primrose  colour.  If  there  has  been  long-standing 
inflammation  of  the  kidney,  the  surrounding  tissues  will  be 
abnormally  firm  and  coherent. 

Through  the  opening  thus  made  in  the  fat  the  finger  is  pushed, 
and  the  surface  of  the  kidney  systematically  explored.  During 
this  examination,  an  assistant,  pressing  on  the  abdominal  sur- 
face, forces  the  kidney  as  much  as  possible  into  the  wound. 
The  anterior  surface  may  be  explored  while  the  kidney  is  lying 
on  the  psoas,  against  which  firm  surface  it  is  pressed.  To 
explore  the  posterior  surface,  the  kidney  is  pulled  forward  and 

compressed  against 
either  a  broad  spatula 
or  the  fingers  of  the  op- 
posite hand.  Lange's 
proposal,  to  examine  the 
pelvis  by  tilting  forward 
the  whole  organ,  is  well 
worthy  of  attention. 
(Fig.  73.)  It  is  cer- 
tainly easier  to  examine 
the  kidney  between  thg 
fingers  when  it  is  well 
pulled  forwards  out  of 
its  bed,  than  when  it  is 
lying  far  back  in  its 
normal  situation. 
Every  particle  of  renal 
tissue  is  rubbed  and 
squeezed  between  the 
fingers,  and  any  hard 
spot  is  noted.  If  the  stone  is  small,  and  if  it  is  overlapped  by 
renal  tissue,  which  may  be  increased  in  density  from  prolonged 
irritation,  it  may  be  impalpable.  In  one  case  of  Morris's,  after 
the  kidney  had  been  removed  and  placed  on  a  table,  it  was 
found  impossible  by  palpation  with  the  finger  to  detect  a  stone 


Fig.  73.     (Lange.) 

Pelvis  and  Ureter  exposed  from  behind  after 
removal  of  Peri-nephric  Fat. 

A,  Kidney ;.  B,  Pelvis  of  Kidney  ;  E,  F,  Quadratus 
Lumborum. 


THE   OPERATION.  527 

which  was  embedded  in  a  calyx.  Of  this  fact  there  can  be  no 
doubt :  a  most  painstaking  examination  with  the  finger  may  fail 
to  detect  a  stone  where  it  is  present. 

Should  a  hard  or  elevated  area  be  made  out,  the  exploring 
needle  is  pushed  into  it,  and  the  stone  felt  for. 

Should  no  stone  be  felt,  the  plan  recommended  by  Jordan 
Lloyd"  should  now  be  adopted.  As  a  result  of  his  anato- 
mical studies  (see  above)  and  practical  experience,  he  con- 
siders it  infinitely  more  reliable  and  quite  as  easy  to  execute  as 
the  ordinary  plan  of  needling.  "  The  procedure  is  analogous  to 
the  method  of  detecting  stone  in  the  bladder,  differing  from  it 
only  in  the  one  particular,  that  we  reach  the  kidney's  interior 
through  an  opening  artificially  made.  When  the  kidney  is 
exposed  through  a  lumbar  wound,  I  puncture  its  lower  end  with 
a  long-bladed  tenotome  in  a  direction  upwards  and  inwards, 
making  for  the  lowest  of  the  calyces.  If  the  surgeon  is  observ- 
ant and  his  knife  is  keen,  he  will  readily  appreciate  the  moment 
when  a  cavity  is  struck  by  the  altered  resistance  offered  to  the 
puncturing  instrument.  .  .  .  Into  this  opening  I  pass  a  child's 
bladder-sound,  and  systematically  explore  the  whole  interior  of 
the  pelvis.  This  sound  should  be  of  special  construction, 
having  a  beak  not  more  than  one-third  of  an  inch  in  length,  a 
stem  about  seven  inches,  and  the  size  of  a  No.  3  English 
catheter.  It  should  be  passed  at  once  to  the  top  of  the  kidney 
cavity,  a  distance  of  nearly  four  inches,  and  the  exploration 
should  be  carried  out  systematically,  from  above  downwards, 
the  point  being  rotated  in  all  directions  so  as  to  investigate 
both  tubes  and  calyces  as  the  instrument  is  withdrawn."  He 
has  succeeded  by  this  plan,  after  needling  and  palpation  have 
both  failed. 

Should  this  plan  fail,  a  systematic  examination  with  explor- 
ing needle  may  be  carried  out.  This  needle  is  a  fine  sharp  steel 
probe,  mounted  on  a  wooden  handle.  It  is  so  fine  that  it  makes 
a  very  small  wound ;  and,  being  only  two  and  a  half  inches  in 
length,  it  cannot,  if  pushed  through  the  cortex,  wound  the  large 
renal    vessels.      The    exploratory    punctures    are    made    in    a 

•  Loc.  cit. 


528  NEPHRO-LITHOTOMY. 

thoroughly  systematic  manner  from  one  end  to  the  other  of  the 
posterior  border.  While  this  is  being  done  with  the  needle  in 
one  hand,  the  kidney  is  steadied  and  held  upwards  in  the  wound 
by  the  fingers  of  the  other  hand.  Every  thrust  ought  to  be 
towards  the  hilum,  so  as  to  strike  the  position  of  the  calyces. 
Should  the  needle  strike  a  stone,  a  long  thin-bladed  knife  is 
pushed  alongside  of  it,  till  it  also  strikes  the  stone,  and  a  vertical 
incision  is  then  made  in  the  renal  tissue  through  which  the  stone 
may  be  extracted. 

Supposing  that  no  stone  is  discovered  after  complete  explo- 
ration with  the  needle,  the  operation  is  not  to  be  abandoned. 
The  kidney  may  be  unhesitatingly  laid  open  by  an  incision 
along  its  posterior  border,  long  enough  to  permit  of  digital 
examination  of  the  calyces.  As  Morris  remarks,  "kidney 
wounds  are  known  to  heal  readily,  and  whilst  the  risk  of  such 
an  incision  would  not  equal  that  of  a  nephrectomy,  the  subse- 
quent condition  of  the  kidney  would  be  preferable  to  the 
possession  of  only  one  of  these  organs."  Instead  of  the  finger, 
a  sound,  such  as  that  of  Lloyd  or  Lucas  or  Bruce  Clarke,*'  may 
be  used.  The  latter  surgeon  made  a  series  of  careful  experi- 
ments in  the  post-mortem  room,  to  test  how  far  it  was  possible 
to  explore  with  a  flexible  sound  the  various  recesses  of  the 
kidney.  He  found  that  with  an  ordinary  bougie  a  houle  with  a 
porcelain  tip  it  was  possible  to  explore  nearly  every  part  of  the 
pelvis  and  calyces. 

Supposing  a  stone  is  felt  in  the  pelvis  of  the  kidney,  it  may 
become  a  question  whether  it  would  not  be  better  directly  to 
extract  it  by  incising  or  tearing  the  pelvis,  than  to  do  so  by 
incising  the  renal  tissue.  The  pelvis  should  be  opened  from 
behind  if  possible,  and  the  instrument  used  ought  not  to  be 
sharp.  After  opening  the  pelvis,  there  is  a  risk  of  urinary 
fistula  ;  therefore,  wherever  it  seems  feasible  and  proper,  ex- 
traction should  be  made  through  an  opening  in  the  renal 
tissue. 

The  first  incision  down  to  the  stone  is  made  large  enough  to 
admit  the  forefinger.  An  attempt  is  made  to  raise  up  the  stone 
*  Surgery  of  the  Kidney.     London,  1886. 


THE  OPERATION.  529 

on  the  finger-pulp,  and  this  manoeuvre  may  be  assisted  by  a 
small  scoop.  The  opening,  if  not  large  enough,  is  increased  by 
tearing  and  dilating.  Haemorrhage  is  controlled  b}-  the  finger, 
acting  as  a  plug,  and  is  rarely  troublesome.  It  is  always  advis- 
able to  remove  the  stone  entire,  if  this  can  be  done  without 
injuring  the  secreting  substance ;  otherwise,  it  must  be  broken 
up.  Bennett  May  has  succeeded  in  removing  entire  from  a 
kidney  but  slightly  enlarged  a  stone  an  ounce  in  weight ;  and  at 
least  one  heavier  has  been  extracted. 

The  removal  of  a  calculus  blocking  the  orifice  of  the  ureter 
may  be  an  affair  of  extreme  difficulty,  taxing  to  the  full  the 
manual  and  mental  resources  of  the  surgeon.  I  have 
assisted  at  such  an  operation  in  which  most  skilful  and 
persevering  efforts  on  the  part  of  one  of  our  most  brilliant 
operators  only  succeeded  after  an  hour's  trial  in  removing  the 
stone. 

Where  the  kidney  is  suppurating,  and  the  stone  lies  in  an 
abscess  sac,  the  operation  may  be  very  eas}^  On  the  other 
hand,  as  in  large  branched  calculi,  it  may  be  impossible  to 
remove  the "  stone  until  it  has  been  broken  into  fragments. 
Each  case  must  be  managed  on  its  own  merits :  a  resourceful 
surgeon  will  at  once  decide  upon  the  most  favourable  plan  of 
removing  the  calculus. 

A  drainage-tube  is  placed  in  the  bottom  of  the  parietal  wound, 
behind  the  kidney  :  the  wound  itself  is  closed  in  the  ordinary 
way  by  deep  and  superficial  sutures.  ¥ox  the  first  day  or  two 
nearly  all  the  urine  escapes  by  the  drainage-tube  :  it  soon  dimin- 
ishes, however  ;  and  after  a  few  days  or  weeks,  ceases  altogether. 
To  prevent  contact  of  the  urine  with  the  wound,  an  attempt 
ought  to  be  made  to  convey  it  into  a  reservoir.  This  may  be 
done  by  using  ordinary  imperforated  rubber  tubing,  making 
holes  in  it  only  for  the  distance  it  extends  into  the  tissues,  and 
carrying  the  external  imperforated  portion  into  a  rubber  bottle 
which  lies  at  some  distance  from  the  patient.  The  tube  should 
be  fixed  in  the  opening  by  a  stitch  including  the  tube  and  the 
skin.  The  wound  is  dressed  with  ordinary  absorbent  material : 
it  usually  heals  with  great  rapidity. 

35 


530  NEPHRO-LITHOTOMY. 

Of  special  dangers  following  nephro-lithotom}-  we  know 
little  ;  for  they  have  not  yet  appeared.  If  haemorrhage  is 
troublesome,  a  catgut  suture  may  be  carried  through  the  renal 
tissue,  so  as  to  exert  compression.  Cellulitis,  renal  abscess, 
and  renal  fistula,  are  mentioned  as  possible  results  by  Morris. 
In  cases  of  advanced  calculous  pyelitis,  the  dangers  are  prac- 
tically those  of  nephrotomy  or  nephrectomy  for  the  same 
condition.  The  question  as  to  the  advisability  of  combining 
abdominal  section  with  lumbar  section  is  but  little  different,  in 
calculous  disease,  from  that  presented  in  non-calculous  disease, 
and  need  not  specially  be  considered  here. 


Puncture  of  the  Kidney,  and  Nephrotomy. 

By  nephrotomy  is  meant  the  operation  of  making  an  incision 
into  the  kidney,  for  the  purpose  of  evacuating  cystic  or  purulent 
collections  of  fluid.  Puncture  of  the  kidney  is  simply  nephro- 
tom}'  done  without  dissection,  and  not  followed  by  drainage ; 
nephrotomy  is  usually  preceded  by  careful  dissection  through 
the  loins,  and  is  nearly  always  followed  by  drainage. 

Puncture,  nephrotomy,  and  nephrectomy  overlap.  Any  one 
of  them  may  be  indicated  for  the  same  condition  ;  and,  indeed, 
all  of  them  ma}^  properly  be  performed  in  succession  for  the 
cure  of  this  condition.  Thus,  in  a  case  of  hydro-nephrosis 
puncture  failing  to  cure,  nephrotomy  with  drainage  may  be 
tried  ;  if  this  also  fails,  nephrectomy  may  be  performed.  Begin- 
ning at  the  other  end,  nephrectomy  as  a  primary  procedure  has 
a  more  limited  application.  It  is  admissible  where  puncture 
and  incision  are  inadmissible,  only  in  the  case  of  new  growths  ; 
in  every  other  condition,  and  especially  in  cysts  and  abscesses, 
it  may  properly  follow  a  want  of  success  in  the  minor  operation 
of  nephrotomy. 

It  is  undoubtedly  the  case  that  for  the  same  disease — scrofu- 
lous kidney,  for  example — nephrotomy  or  nephrectomy  may  be 
performed  with  equal  propriety.  But  the  actual  stage  or  con- 
dition of  the  disease  ought  to  be  very  different  for  each  operation. 
It  is  impossible,  therefore,  to  classify  the  indications  for  opera- 
tion under  the  heads  of  the  pathological  condition  for  which  the 
operation  may  be  performed.  It  will  serve  our  purpose  of 
description  better,  and  at  the  same  time  emphasise  the  best 
recognised  practice,  if  under  each  operation  we  consider  only 
such  diseases  as  directly  and  specially  call  for  it.  For  some  of 
them,  puncture  ought  first  to  be  performed ;  if  this  fails,  nephro- 
tomy ought  to  follow ;  if  this  also  fails,  nephrectomy  may  be 
called  for.  In  others,  the  first  proceeding  ought  to  be  nephro- 
tomy; if  this  fails,  nephrectomy  may  be  demanded.  Nephro- 
tomy  also    may  sometimes    be    regarded    as    preparatory   to 

35  * 


532        PUNCTURE  OF  THE  KIDNEY  AND   NEPHROTOMY. 

nephrectomy.       In    a    third    class,    nephrectomy   ought    to    be 
performed   at   first. 

The  following  classification  may  be  adopted  as  practically 
convenient : 

Renal  Puncture,  indicated  in — 
(i)  Simple  cysts. 

(2)  Hydro-nephrosis. 

(3)  Hydatid  cysts. 

Nephrotomy,  indicated  in — 

(i)  Cases  where  puncture  fails. 

(2)  Pyo-nephrosis. 

(3)  Suppurative  nephritis  and  pyelo-nephritis. 

(4)  Scrofulous  kidney. 

(5)  Calculous  suppression  of  urine. 

Nephrectomy,  indicated  in — 

(i)  Cases  where  nephrotomy  fails,  or  would  evidently  be 

useless. 
(2)  Certain  new  growths  of  the  kidney. 
{3)  Ureteral  and  renal  fistulae. 
{4)  Serious  wounds  of  the  kidney. 
(5)  Disease  or  degeneration  of  movable  kidney. 


Puncture  of  the  Kidney. 

CONDITIONS    FOR    WHICH    THE    OPERATION    MAY    BE    PERFORMED. 

Puncture  of  the  kidney  may  be  employed  in  any  form  of 
renal  cystic  enlargement ;  but  it  is  primarily  indicated  as  a 
curative  measure  only  in  simple  and  hydatid  cysts,  and  in 
hydro-nephrosis. 

Simple  Cysts  of  the  Kidney. — Here  we  are  not  concerned  with 
those  small  cysts  so  frequently  found  in  granular  kidneys ;  nor 
with  the  rare  general  transformation  into  numerous  cysts  found 
congenitally  or  in  adults.  The  former  never  attain  to  surgical 
dimensions  ;  the  latter,  general  cystic  degeneration,  being  bi- 
lateral, is  not  amenable  to   surgical  treatment. 

Simple  serous  cysts  are  found  as  thin  -  walled  globular 
tumours,  of  varying  dimensions,  springing  from  some  part  of 
the  renal  cortex.  Their  contents  are  not  urinous,  but  a  pale 
straw-coloured  fluid,  of  low  specific  gravity,  containing  a  con- 
siderable amount  of  albumen.  Sometimes  the  cavity  of  the  cyst 
communicates  by  an  opening  with  one  of  the  calyces ;  most 
frequently  it  is  blind.  The  fluid  often  contains  cholesterine, 
and  occasionally  blood.  Rarely  the  contents  are  thick,  or  of  the 
consistence  of  jelly. 

These  cysts  are  harmful  only  when  they  attain  to  large 
dimensions.  They  tend  to  distort,  spread  out,  and  cause 
atrophy  of  the  proper  renal  tissue,  as  well  as  to  interfere  with 
health,  from  their  bulk. 

The  symptoms  are  simply  those  of  a  slowly  growing  cystic 
tumour,  situated  in  the  loin.  There  are  no  special  signs  avail- 
able for  diagnosis.  Urinary  symptoms  are  absent ;  and  there  is 
no  pain,  or  pyrexia,  or  evidence  of  ill-health.  Diagnosis  can  be 
made  only  by  exclusion  of  other  forms  of  cystic  enlargement. 

Para-nephric  Cysts  are  rare  developments  of  doubtful  origin, 
which  arise  in  the  tissues  immediately  surrounding  the  kidney, 


534  PUNCTURE   OF  THE  KIDNEY. 

and  sometimes  form  a  connection  with  it.  They  may  be  con- 
genital. Chnically,  they  are  undistinguishable  from  simple 
cysts ;  practically,  their  recognition  is  unimportant,  as  the 
treatment  is  identical. 

Hydatid  Cysts  of  the  Kidney. — Hydatids  are  found  in  the 
kidney  six  times  less  frequently  than  in  the  liver.  In  a  con- 
siderable majority  of  cases,  the  left  kidney  is  the  organ  affected  ; 
very  rarely  are  both  organs  affected  at  once. 

The  cyst  usually  originates  in  the  secreting  substance ;  but 
occasionally  develops  in  the  cellular  tissue  underlying  the 
capsule  or  surrounding  the  pelvis.  The  renal  tissue  is  thinned 
out  and  atrophied,  from  pressure.  As  compared  with  hydatids 
of  other  organs,  renal  hydatids  do  not  attain  to  very  large 
dimensions  ;  this  is  probably  due  to  a  tendency  which  they  have 
to  discharge  a  portion  of  their  contents  through  the  ureter. 
Of  63  cases  of  renal  hydatids  collected  by  Roberts,  a  history 
of  vesicles  passed  in  the  urine  occurred  in  52.  A  renal  hydatid 
cyst  containing  four  pints  of  fluid  would  be  considered  a  large 
one.  It  may  burst  into  surrounding  organs,  as  the  intestine  or 
lung  ;  and  it  may  undergo  any  of  the  inflammatory,  degener- 
ative, or  atrophic  changes  which  are  found  in  hydatids  else- 
where. Hydro-nephrosis  has  been  caused  by  the  impaction  of 
a  vesicle  in  the  ureter. 

The  symptoms  of  renal  hydatid  disease  are :  the  passage  of 
hydatid  vesicles  in  the  urine,  preceded  by  attacks  of  renal  colic  ; 
and  the  existence  of  an  abdominal  tumour,  fixed  in  the  loin. 
Sometimes  there  is  a  discharge  of  hydatids,  and  no  tumour ; 
more  rarely  is  there  a  tumour,  and  no  h3^datid  escape.  In  only 
18  of  Roberts's  63  cases  was  a  tumour  discernible.  Fluctuation 
is  not  always  perceptible  ;  and  the  hydatid  fremitus  is  as  rarely 
observed  here  as  in  the  liver  or  elsewhere.  The  vesicles  are 
found  entire  or  ruptured  ;  occasionally  nothing  is  found  in  the 
urine  but  booklets  and  shreds  of  membrane.  Blood  or  pus 
may  be  discharged  with  the  hydatids  :  these  are  specially 
frequent  after  attacks  of  renal  colic.  Retention  of  urine  has 
been   caused  by  blocking  of  the  urethra ;   and,  as  already  re- 


HYDRO-NEPHROSIS.  635 

marked,  hydro-nephrosis  may  arise  from  blocking  of  the  ureter. 
In  the  bladder,  the  vesicles  may  beget  symptoms  of  irritation  or 
tenesmus,  or  even  inflammation  :  impacted  in  the  ureter,  the 
vesicles  may  set  up  the  train  of  symptoms  already  described  as 
characteristic  of  renal  colic,  from  the  passage  of  calculus. 

Hydro-nephvosis. — This  is  a  distension  of  the  kidney  with  fluid, 
caused  by  an  obstruction  to  the  flow  of  urine.  The  obstruction 
may  exist  at  any  point  in  the  urinary  tract — urethra,  bladder, 
ureter,  or  pelvis  of  the  kidney.  It  may  be  congenital  or  acquired. 
According  to  Morris,  about  one-third  of  the  cases  have  a  con- 
genital cause ;  but  in  some  cases  this  cause  does  not  have  its 
full  effect  in  producing  hydro-nephrosis  till  late  in  life.  "  Con- 
genital nephrosis "  must  not  be  confounded  with  "  hydro- 
nephrosis having  a  congenital  cause." 

Congenital  causes  of  hydro-nephrosis  are  numerous  and 
various.  In  the  ureter,  twists,  kinks,  reduplications  or  folds, 
stenosis,  and  complete  obliteration,  have  all  been  described  as 
causes.  The  junction  of  the  ureter  to  the  kidney  or  to  the 
bladder  may  be  faulty,  obstructing  the  flow  of  urine.  Compres- 
sion of  the  ureter  by  abnormal  arteries  has  been  described  as  a 
cause  of  hydro-nephrosis. 

Of  acquired  causes,  the  most  important,  from  a  surgical 
point  of  view,  is  impaction  of  a  calculus  in  the  ureter  or  pelvis 
of  the  kidney.  In  an  elaborate  investigation  into  the  causes  of 
142  cases  of  marked  hydro-nephrosis  extracted  from  the  post- 
mortem records  of  Middlesex  Hospital,  Morris  found  that  116 
cases  had  cancer  of  the  pelvic  organs,  uterus,  vagina,  bladder, 
or  rectum  ;  2  had  cancer  of  the  ovaries  ;  and  the  remaining 
24  had,  in  about  equal  proportions,  cystitis,  vesical  calculus, 
enlarged  prostate,  ovarian  cyst,  constriction  of  ureter,  cancer  of 
abdominal  organs :  in  one  there  was  a  villous  growth  of  the 
bladder  ;  in  4  the  causes  were  imknown.  Roberts  found  in  32 
cases  of  hj^dro-nephrosis  the  causes  to  be — impaction  of  calculus 
in  the  ureter  in  11,  and  probably  in  3  more;  in  5,  cicatricial 
stenosis  of  the  ureter  ;  in  6,  compression  of  the  ureter  b}^  pelvic 
tumours ;    and  in   3,  compression    by  inflammatory  peritoneal 


536  PUNCTURE  OF  THE  KIDNEY. 

bands.  Retroflexion  of  the  uterus  has  been  described  as  a 
cause ;  and  Morris  and  James  have  explained  how  greatly  in- 
creased frequency  of  micturition  may  produce  hj'dro-nephrosis. 
The  most  elaborate  investigation  into  the  causation  of  acquired 
hydro-nephrosis  has  been  carried  out  by  Newman.*  Of  a  total 
of  665  cases,  tumours  of  the  pelvic  organs  causing  pressure  on 
the  ureters  were  the  causes  in  184,  stricture  of  the  urethra  and 
enlarged  prostate  in  234,  tumours  or  abscesses  of  pelvic  organs 
leading  to  tortion  of  the  ureters  in  32,  renal  calculi  in  68, 
displacements  of  the  kidney  in  17,  tumours  of  the  bladder  in  10, 
and  bands  and  adhesions  in  12. 

Hydro-nephrosis  is  about  equally  common  in  both  kidneys ; 
in  about  one-third  of  the  cases  it  exists  in  both  at  the  same 
time.  It  is  found  at  all  ages,  and  with  equal  frequency  in  both 
sexes.  From  an  analysis  of  69  cases  of  hydro-nephrosis  and 
pyo-nephrosis,  Dickinson  concludes  that  death  from  one  or  other 
of  these  closel3^-allied  complaints  "  is  especially  frequent  during 
the  first  ten  years  of  life,  as  the  result  of  congenital  lesions  ;  as 
an  acquired  disease,  largely  due  to  stone,  it  produces  its  fatal 
issue  with  increasing  frequenc}'  up  to  50,  beyond  which  age  it  is 
seldom  delayed." 

As  to  the  actual  lesion  produced,  it  may  affect  the  whole 
kidney,  or  only  part  of  it ;  that  is  to  say,  the  distension  may 
involve  the  whole  pelvis,  or  only  a  few  of  the  calyces.  A  case 
has  been  recorded  in  which  a  tumour  of  considerable  size  was 
caused  by  the  distension  of  one  calyx.  The  mode  of  distension 
is  easil}'  understood.  The  pelvis  is  first  converted  into  a  globular 
sac ;  the  calyces  then  become  dilated  ;  and  lastly  the  medullary 
and  cortical  portions  are  stretched  out  and  thinned.  In  extreme 
cases,  the  secreting  tissue  ma}'  be  represented  by  a  thin  layer 
underlying  the  capsule ;  or  all  traces  of  it  may  disappear,  and 
the  kidney  is  little  more  than  a  cyst  with  thin  fibrous  walls  sub- 
divided internally  into  secondary  cysts  or  saccules  by  complete 
or  incomplete  septa.  In  most  cases  some  trace  of  secreting 
tissue  remains,  with  something  of  the  kidney  shape.  In  size  the 
sac  varies  from  that  of  the  normal  kidney,  or  less,  to  dimensions 
*  Surg.  Dis.  of  Kidney,  1888,  p.  114. 


HYDRO-NEPHROSIS.  537 

sufficient  to  fill  the  abdominal  cavity.  In  only  a  small  propor- 
tion of  cases,  however,  does  hydro-nephrosis  attain  to  a  size 
sufficient  to  cause  perceptible  tumefaction  of  the  abdomen. 

The  fluid  in  the  cyst  is  never  pure  urine;  frequently  it  con- 
tains neither  urea  nor  uric  acid.  It  is  usually  a  simple,  clear, 
aqueous  fluid,  of  low  specific  gravit}',  containing  a  little  chloride 
of  sodium  and  perhaps  albumen.  Occasionally  the  fluid  is 
brown,  from  admixture  with  blood  ;  rarely  it  is  thick  or  colloi- 
dal ;  and  sometimes  it  is  putrid,  ammoniacal,  and  turbid. 

It  has  been  pointed  out  that  the  obstruction  in  the  most 
typical  cases  of  hydro-nephrosis  is  not  complete  and  not  con- 
tinuous. A  cpmplete  obstruction  to  the  urinary  flow  leads  to 
atrophy,  rather  than  to  dilatation  of  the  kidney ;  stricture, 
varying  in  narrowness,  predisposes  to  dilatation.  A  calculus  in 
the  pelvis  or  the  ureter,  occasionally  moving,  causing  at  one  time 
partial,  at  another  time  complete  obstruction,  while  it  some- 
times moves  out  of  the  way  altogether,  provides  the  ideal  cause 
of  hydro-nephrosis,  such  as  comes  up  for  surgical  treatment. 

Symptoms  of  hydro-nephrosis,  in  the  absence  of  a  tumour, 
are  usually  wanting  altogether;  in  the  worst  cases  there  ma}'  be 
symptoms  of  urinary  suppression.  In  disease  of  both  kidneys, 
uraemia  sooner  or  later  appears.  Diagnosis  is  possible,  or  rather 
probable,  only  when  a  tumour  is  present.  Such  a  tumour  is 
rounded,  often  lobulated,  usually  fluctuating,  and  lies  mainly  in 
the  loin.  If  the  tumour  is  very  large,  it  may  occupy  and 
distend  the  whole  abdomen,  on  one  side  as  much  as  on  the 
other  ;  in  such  a  case,  a  histor}^  of  its  having  once  been  one- 
sided, or  of  its  having  appeared  in  the  costo-iliac  interspace, 
will  be  of  assistance.  In  every  case,  a  history  of  its  varying  in 
size  is  of  importance  — almost  pathognomonic,  in  fact.  Morris 
has  recorded  eleven  cases  where  the  tumour  completely  inter- 
mitted ;  that  is,  where  it  was  prominent  at  one  time,  and  not 
distinguishable  at  another.  Many  others  show  temporary 
diminution  without  actually  vanishing.  If,  with  the  diminution 
or  disappearance  of  the  tumour,  there  is  observed  an  increased 
flow  of  urine  of  low  specific  gravity,  we  ma}'  almost  certainly 
diagnose  hydro-nephrosis. 


538  PUNCTURE   OF  THE   KIDNEY. 

As  to  subjective  symptoms,  records  are  extremely  variable. 
Frequently  there  is  no  pain  whatever  ;  sometimes  there  is  severe 
pain,  occasionally  amounting  to  agony.  The  amount  of  tension 
and  the  presence  of  a  calculus  would  influence  the  production  of 
pain. 

The  diagnosis  of  hydro-nephrosis  is  often  difficult,  sometimes 
impossible.  It  may  be  mistaken  for  any  cystic  abdominal 
tumour.  Of  renal  cystic  enlargements,  it  is  most  liable  to  be 
confounded  with  simple  or  hydatid  cyst,  and  with  pyo-nephrosis. 
In  hydatids  the  history  gives  most  important  aid.  In  pyo- 
nephrosis, elevation  of  temperature  with  continuous  or  occasional 
presence  of  pus  in  the  urine,  may  be  expected.  Hydatids  of 
liver  or  spleen  may  mislead.  But,  when  the  tumour  is  large,  it 
is  most  frequently  mistaken  for  ovarian  cystoma;  at  least  fifteen 
cases  are  on  record  in  which  hydro-nephrotic  or  simple  renal 
cysts  have  been  mistaken  for  ovarian  tumour,  and  laparotomy 
performed  on  the  erroneous  diagnosis.     (Morris.) 


THE    OPERATION    OF    PUNCTURING    THE    KIDNEY. 

This  operation  may,  with  a  fair  promise  of  cure,  be  performed 
for  any  of  the  above  conditions;  viz.,  simple  cyst,  hydatid,  and 
hydro-nephrosis.  In  the  case  of  simple  cysts,  tapping  may  be 
repeated  several  times  should  the  cyst  refill.  In  hydatid  disease, 
tapping  may  be  successful,  and  should  be  tried  ;  but  incision, 
with  drainage,  is  likely  to  be  called  for.  If  there  is  no  discharge 
of  vesicles  by  the  urethra,  Morris  considers  that  the  only 
proper  treatment  is  nephrotomy.  The  first  proceeding,  in  all 
cases  of  hydro-nephrosis  calling  for  treatment,  ought  to  be 
tapping.  Friction  and  compression  by  the  hands  have  caused 
several  hydro-nephrotic  tumours  to  disappear  ;  but  in  few  cases 
can  manipulation  be  entirely  free  from  risk,  and  in  the  great 
majority,  from  the  nature  of  the  obstruction,  it  must  be  useless. 
A  single  tapping  is  rarely  curative  in  hydro-nephrosis;  frequently 
the  operation  has  had  to  be  repeated  many  times.  But  if,  after 
three  or  four  tappings  have  been  tried,  a  cure  is  not  effected, 


THE  OPERATION.  539 

most  surgeons  would  proceed  to  incision  and  drainage.  Repeated 
tapping  is  liable  to  beget  suppuration. 

Puncture  and  tapping  of  the  kidney  is  best  performed  with 
the  aspirator.  The  needle  should  be  of  large  size,  to  lessen  the 
chance  of  its  becoming  blocked  with  debris.  The  skin  and  the 
needle  must  be  thoroughly  aseptic  ;  and  the  needle  ought  to  be 
introduced  full  of  an  aseptic  fluid,  to  prevent  the  introduction  of 
air  into  the  cyst.  An  air-bubble  will  rise  into  a  sac  of  fluid  out 
of  the  point  of  an  aspirator  needle,  and  filthy  epidermic  scales 
m.aj'  be  carried  in  on  the  cutting  point.  An  abundant  experience 
of  this  very  simple  operation  proves  that  it  is  too  frequently 
allied  to  the  experiment  of  introducing  a  germ-laden  needle  into 
the  midst  of  a  cultivation  jelly. 

The  point  at  which  puncture  is  to  be  made  will  vary  accord- 
ing to  the  size  of  the  tumour,  its  nature,  and  the  side  on  which 
it  lies.  In  every  case  the  operation  ought  to  be  extra-peritoneal; 
the  needle,  therefore,  must  not  be  inserted  too  far  forwards. 
Morris  advises  that  "  if  there  be  any  spot  over  the  swelling 
which  is  thin,  soft,  prominent,  or  fluctuating,  the  trocar  should 
be  there  inserted.  A  point  which  is  not  seldom  indicated  is 
midway  between  the  umbilicus  and  the  anterior  superior  spine 
of  the  ilium  ;  or  half  an  inch  below,  and  an  inch  and  a  half 
to  the  side  of  the  navel."  One  danger  in  puncturing  too  near 
to  the  middle  line  is,  that  the  colon  may  be  wounded. 

Where  the  tumour  is  not  large,  or  where  no  favourable  spot 
presents  itself,  the  site  to  be  selected  should  be  regulated  by 
the  anatomy.  As  a  result  of  several  experiments,  Morris  found 
that,  to  puncture  the  left  kidney,  the  best  point  of  entrance  was 
one  "just  anterior  to  the  last  intercostal  space."  On  the  right 
side,  puncture  in  this  situation  would  probably  traverse  the 
liver ;  therefore,  a  lower  point  is  selected  half-way  between  the 
last  rib  and  the  crest  of  the  ilium,  from  two  to  two  and  a  half 
inches  behind  the  anterior  superior  spine  of  the  ilium.  "  This 
spot  is  on  a  level  with  the  front  of  the  bodies  of  the  lumbar 
vertebrae,  and  a  needle  here  passed  horizontally  inwards  will  be 
altogether  in  front  of  the  normal  kidney,  and  will  either  transfix 
or  pass  in  front  of  the  ascending  colon  when  in  its  usual  place. 


540  PUNCTURE   OF  THE  KIDNEY. 

It  may,  however,  with  safety  be  conjectured  that,  in  any  case  of 
hydro-nephrosis  of  the  right  side  requiring  to  be  tapped,  if  the 
trocar  be  inserted  at  the  place  I  propose,  and  directed  somewhat 
forwards,  the  peritoneum  and  colon  will  be  sufficiently  in  front 
to  escape  injur}' ;  the  liver  will  be  safely  out  of  reach  above,  and 
the  kidney  behind ;  while  the  dilated  pelvis  of  the  kidney  will  be 
tapped  at  its  anterior  and  lower  aspect."     (Morris.) 

As  soon  as  the  needle  is  embedded  in  the  skin,  the  exhausting 
bottle  should  be  connected ;  and  the  needle  is  then  cautiously 
pushed  onwards  till  fluid  is  sucked  out,  when  it  should  be 
pushed  in  no  further.  Thus  the  risk  of  wounding  renal  vessels 
is  diminished.  More  than  one  case  has  died  from  extravasation, 
of  the  cyst-contents  into  the  peritoneal  cavity.  Wound  of  the 
margin  of  the  liver  may  prove  harmless.  The  risk  of  wounding 
the  pleura  has  alread}'  been  referred  to. 


Nephrotomy. 

CONDITIONS    FOR    WHICH    NEPHROTOMY    MAY    BE    PERFORMED. 

Pyo-nephrosis  is  simply  hydro-nephrosis  with  suppurative 
inflammation  of  the  Hning  membrane  of  the  cyst.  Between  a 
simple  catarrh  with  shedding  of  proliferative  endothelial  cells, 
and  the  formation  of  granulations  with  abundant  discharge  of 
pus,  all  degrees  of  inflammation  are  found.  Mucus,  blood,  and 
urine  are  frequently  found  in  the  purulent  fluid  ;  occasionally  it 
is  very  putrid.  In  certain  cases,  phosphates  are  found  in 
sufficient  amount  to  form  with  the  pus  a  sort  of  paste. 

Pyo-nephrosis  may  be  the  first  effect  of  a  calculus;  or  it  may 
be  an  after-development  of  hydro-nephrosis,  either  spontaneously 
evolved,  or  as  a  result  of  surgical  interference  by  tapping.  It 
may  originate  in  any  of  the  conditions  alread}^  mentioned  as  pro- 
ductive of  hydro-nephrosis,  and  more  particularly  from  renal 
calculus.  Suppurative  calculous  pyelitis  has  already  been 
described  under  nephro-lithotomy,  and  need  not  be  further 
dwelt  upon. 

The  symptoms  are  those  of  hydro-nephrosis //«s  suppuration. 
Elevation  of  temperature,  with  or  without  rigors  ;  hectic  ;  loss 
of  appetite,  with  perhaps  symptoms  of  ursemia  or  septicaemia, 
may  be  looked  for.  A  tumour  may  be  visible  and  palpable ;  but 
it  rarely  attains  to  the  enormous  dimensions  sometimes  observed 
in  hydro-nephrosis.  Dulness,  if  the  tumour  is  large,  may  be 
interrupted  towards  the  middle  line  by  the  colon  passing  over  it. 
Fluctuation  may  or  may  not  be  detected.  A  lobulated  outline  on 
palpation  maybe  frequently  made  out.  Pain,  cutaneous  oedema 
or  redness,  and  other  local  signs  of  suppuration,  may  be 
expected.  An  examination  of  the  urine  may  reveal  the  presence 
of  pus,  and  an  estimation  of  its  quantity  ma)'  show  a  diminution 
in  amount.  Intcrmittence  of  the  tumour  has  been  found. 
Occasionally  cystitis  is  set  up,  from  contamination  with  purulent 
or  putrid  urine. 


642  NEPHROTOMY. 

Suppurative  Diseases  of  the  Kidney. — There  are  various  distinct 
forms  of  suppurative  inflammation  of  the  kidney.  They  may  be 
described  as:  (i)  simple  circumscribed  renal  abscess;  (2)  general 
suppurative  nephritis,  pyelitis,  and  pyelo-nephritis;  (3)  scrofulous 
kidney.  Such  a  classification  is  neither  cHnically  nor  pathologi- 
cally perfect  ;  it  is,  however,  that  usually  followed,  and  may  be 
conveniently  adopted  here. 

(i)  Renal  Abscess  has  its  typical  origin  in  injury,  as  from  a 
blow,  or  a  calculus,  or  other  foreign  body  :  it  may  be  secondary 
to. peri-nephric  suppuration;  and  it  has  been  known  to  follow 
the  administration  of  cantharides  and  turpentine.  A  single 
abscess  may  be  formed  by  the  fusion  of  many  small  ones ;  and 
there  may  be  more  than  one  abscess  in  the  kidney. 

Renal  abscess  is  usually  limited  to  one  kidney.  It  may  find 
its  way  into  the  pelvis,  and  thence  empty  itself  into  the  bladder 
through  the  urethra ;  or  it  may  burst  through  the  capsule  into 
the  surrounding  cellular  tissue,  causing  peri-nephric  abscess  ;  or 
both  events  may  occur.  It  is  by  no  means  rare  to  find  more 
than  one  abscess  in  the  renal  tissue.  In  many  cases  the  whole 
organ  is  transformed  into  an  abscess,  limited  by  pelvis  and 
capsule,  and  partly  subdivided  by  septa. 

In  acute  cases,  the  symptoms  are  frequently  ushered  in  with 
rigors,  frequently  repeated,  and  great  elevation  of  temperature. 
In  chronic  cases  there  may  be  little  or  no  fever  at  any  stage  of 
the  disease.  Pain  in  the  region  of  the  kidney  is  usually  com- 
plained of.  Pus  may  be  found  in  the  urine;  if  it  is  considerable  in 
amount,  and  accompanied  with  decrease  in  the  size  of  a  lumbar 
tumour,  the  existence  of  renal  abscess  is  almost  certain.  A  sense 
of  increased  resistance  in  the  loin  to  the  examining  fingers, 
oedema  and  redness  of  skin,  and  complaints  of  local  pain  on 
pressure,  suggest  renal  abscess.  The  disease  is  always  attended 
by  great  prostration,  rapid  emaciation,  and  complete  loss  of 
appetite. 

(2)  Suppurative  Nephritis  is  usually  described  as  secondary  to 
some  disease  of  the  lower  urinary  tract.  It  may  be  confined  to 
the  pelvis,  when  it  is  known  as  pyelitis  ;  or  to  the  kidney,  when 
it  is  described  as  nephritis  ;  or  it  may  involve  the  whole  rena 


SCROFULOUS   KIDNEY.  543 

organ,  when  it  is  known  as  pyelo  -  nephritis.  In  its  typical 
development  it  is  best  known  as  "  surgical  kidney  ;  "  that  is  to 
say,  it  has  its  origin  in  any  disease  of  the  penis  or  bladder  for 
which  surgical  treatment  has  been  or  may  be  instituted.  As  a 
matter  of  fact,  the  disease  is  more  frequently  caused  by  want  of 
surgical  treatment  than  by  excessive  or  erroneous  application 
of  it. 

From  the  nature  of  the  disease,  both  kidneys  are  usually 
affected  ;  and  this  fact  is,  in  itself,  sufficient  to  forbid  a  local 
operation  of  any  magnitude.  Suppurative  nephritis  is,  in  the 
great  majority  of  cases,  a  rapidly  fatal  complaint ;  and  surgical 
treatment  offers  little  or  no  hope  of  cure. 

(3)  Scrofulous  Kidney — or  scrofulous  pyelo-nephritis,  as  it  is 
sometimes  called- — is  an  inflammation  of  the  kidney,  attended 
with  the  formation  of  the  characteristic  cheesy  material.  It  is 
a  constitutional  disease.  Of  95  cases  reported  by  Dickinson  in 
which  death  took  place  from  scrofulous  kidney,  only  11  were 
free  from  similar  disease  in  the  other  kidney  or  elsewhere.  As 
these  were  all  cases  of  death  from  scrofulous  kidney,  it  is  prob- 
able that  the  proportion  of  intercurrent  disease  would  be  higher 
than  when  the  patient  first  came  under  observation.  Still,  in 
the  view  of  operative  proceeding,  the  undoubted  frequency  of 
outlying  scrofulous  mischief  in  cases  of  scrofulous  kidney  ought 
to  teach  caution. 

The  appearance  of  a  typically  scrofulous  kidney  is  charac- 
teristic and  unmistakable.  The  organ  is  enlarged  as  a  whole — 
sometimes  to  three,  four,  or  even  six  times  the  normal  dimen- 
sions. On  section,  aggregations  of  the  well-known  cheesy 
products  are  seen  replacing,  and  more  or  less  accurately  fol- 
lowing, the  outlines  of  the  individual  lobules.  These  cheesy 
masses  are  partially  divided  from  each  other  by  incomplete 
septa,  representing  the  divisions  between  the  lobules,  and 
containing  remnants  of  the  original  secreting  tissue.  On 
these  septa,  and  on  the  inner  surfaces  of  the  capsule  and  the 
pelvis,  ragged  cedematous  granulations  are  exposed  when  the 
purulent  material  is  removed.  Sometimes  the  abscesses  are 
large,  while  the  septa  between  them  are  thin  and  short ;  in  such 


544  NEPHROTOMY. 

cases  p3'elitis  will  be  superadded  to  nephritis.  In  other  cases, 
the  abscesses  are  small  and  the  septa  are  very  thick.  The 
inflammation  spreads  from  the  pelvis  down  the  ureter,  which 
also  becomes  thickened  in  its  walls  and  ulcerated  on  its  surface. 
This  thickening  and  ulceration  of  the  ureter  frequently  descends 
as  far  as  the  bladder,  and  is  one  of  the  characteristic  concomi- 
tants of  such  scrofulous  kidneys  as  may  be  brought  under  oper- 
ative treatment. 

The  symptoms  of  scrofulous  disease  of  the  kidney  are  often 
obscure  or  misleading.  Occasionally  there  are  no  local  signs, 
only  vague  general  signs  of  ill  health,  with  perhaps  slight  indi- 
cations of  urinary  disorder.  Usually  there  is  continuous  pain 
in  the  loins  of  a  dull  aching  or  dragging  character.  But  this 
pain  is  often  aggravated,  occurring  in  paroxysms,  as  in  renal 
colic,  and  due,  in  all  probability,  to  blocking  of  the  ureter  by 
debris.  Pus  in  the  urine  is  a  very  constant  sign  of  scrofulous 
kidney :  its  presence  in  the  bladder  may  set  up  irritation,  or 
even  strangury,  and  lead  to  a  suspicion  of  calculus.  Blood  also 
is  often  mixed  with  the  pus  in  the  urine,  and  more  particularly 
during  the  early  stages  of  the  disease.  Granular  detritus,  and 
pieces  of  cheesy  matter,  soluble  on  the  addition  of  acetic  acid, 
are  often  detected  on  microscopical  examination.  I  have  been 
concerned  in  the  treatment  of  two  cases  of  scrofulous  kidney  in 
which  tubercle-bacilli  were  found  in  the  urine;  and  others 
have  had  a  similar  experience.  Locally  a  hard  tender  swelling 
in  the  region  of  the  kidney  may  usually  be  felt.  Elevations  of 
temperature  occurring  at  irregular  intervals,  lasting  for  short 
periods,  and  accompanied  often  with  rigors  and  sweating,  are 
said  to  be  characteristic.  The  patient  rapidly  loses  strength 
and  flesh  ;  the  skin  becomes  dry  and  hard;  diarrhoea  and  sick- 
ness set  in  ;  and  death  takes  place  from  exhaustion. 

Scrofulous  kidney  is  liable  to  be  confounded  with  cancer  of 
the  kidney,  pyo-nephrosis,  calculous  pyelitis,  and  even  with 
certain  diseases  of  the  bladder  or  prostate.  The  presence  of 
blood  in  the  urine,  and  the  hardness  of  the  growth  in  scrofulous 
kidne}^  are  the  conditions  which  may  give  rise  to  a  diagnosis  of 
cancer.     Abundance  of  pus  in  the  urine,  with  granular  detritus 


PERI-NEPHRIC  ABSCESS.  545 

and  perhaps  bacilli,  and  elevation  of  temperature,  are  mainly  to 
be  relied  on  as  diagnostic.  From  other  forms  of  suppurative 
inflammation,  the  history  and  the  hectic  character  of  the  tem- 
perature will  be  the  most  important  elements  in  differentiation. 

Pevi-nephric  Abscess  is  in  most  cases  a  sequence  of  suppuration 
in  the  kidney  itself.  It  occurs  also  as  a  primary  idiopathic 
disease,  quite  independently  of  the  kidney,  and  also  as  a  con- 
sequence of  urinar}^  extravasation  or  renal  fistula.  As  a  primary 
disease,  it  is  usually  an  effect  of  injury  of  some  sort.  Occa- 
sionally it  occurs  as  a  sort  of  metastasis,  from  operation  upon, 
or  inflammation  in,  distant  parts  of  the  urinary  or  generative 
organs  :  and  not  infrequently  there  is  a  visible  and  continuous 
connection  between  suppurating  inflammations  in  distant  parts 
and  the  peri-nephric  abscess.  The  historic  nephro-lithotomy 
was  essentially  the  evacuation  of  a  peri-nephric  abscess,  which 
contained  a  calculus  that  had  ulcerated  its  way  through  the 
renal  tissues. 

Rarely  does  a  peri-nephric  abscess  burst  through  the  peri- 
toneum. Rather  does  it  burrow  in  various  directions  along  the 
fasciae  surrounding  the  contiguous  muscles,  ultimately  reaching 
the  surface  somewhere  in  the  loin  :  not  infrequently  the  matter 
gets  into  the  sheath  of  the  psoas,  and  reaches  the  inguinal  region, 
after  the  manner  of  a  psoas  abscess.  With  curious  frequency 
the  matter  finds  its  way  through  the  diaphragm  into  the  lungs, 
and  is  expectorated.  I  have  removed  a  vesical  calculus 
weighing  more  than  nine  ounces  from  a  man  who  had  a  sinus 
between  the  seventh  and  eighth  ribs,  which  led  downwards  to  a 
peri-nephric  abscess,  and  upwards  into  a  pulmonary  fistula, 
through  which  pus  was  discharged  in  large  quantities  by  the 
mouth.  Peri-nephric  abscess  has  been  known  to  burst  into  the 
colon,  the  duodenum,  and  even  into  the  bladder. 

The  symptoms  of  peri-nephric  abscess  arc,  in  the  first  place, 
those  of  deep-seated  suppurative  inflammation,  with  its  ordinary 
local  and  general  concomitants,  situated  in  the  tissues  surround- 
ing the  kidney.  P''urther  special  signs  have  been  observed:  such 
are,  lameness  on  the  affected  side,  with  flexion  of  and  inability 

36 


546  NEPHROTOMY 

to  extend  the  thigh,  due  to  involvement  of  the  psoas,  and  oedema 
of  the  foot  and  ankle.  Dr.  John  Roberts  of  Philadelphia,"  after 
an  elaborate  study  of  the  condition,  gives  directions  for  the 
localising  of  peri-nephric  abscess  as  follows :  in  all  anterior 
regions,  we  may  expect  pain,  tenderness,  swelling,  oedema,  or 
pointing  in  front,  or  at  the  side,  of  the  abdomen.  In  all  posterior 
regions,  we  look  for  pain,  tenderness,  swelling,  oedema  or  point- 
ing in  the  loin.  In  the  upper  tracts,  peri-nephric  abscess  will 
probably  cause  pleuritic  friction,  pleural  effusion,  empyema, 
expectoration  of  pus,  and  dyspnoea ;  pn  the  right  side  we  may 
expect  to  find  oedema  of  both  legs,  jaundice,  fatty  stools,  persis- 
tent vomiting,  rapid  emaciation,  and  ascites.  In  the  middle 
tracts,  there  may  be  albuminuria  and  casts;  supra-pubic,  scrotal, 
or  vulvar  pain,  or  anaesthesia  ;  suppression  of  urine  ;  ura3mia  ; 
pyuria;  oedema  of  the  scrotum.  In  the  lower  tracts,  he  tells  us 
to  expect  with  peri-nephric  abscess,  flexion  of  the  hip ;  pain  or 
anaesthesia  in  the  front,  the  outside,  or  the  inside  of  the  thigh  ; 
pain  in  the  knee ;  scrotal  or  vulvar  pain,  or  anaesthesia,  without 
albuminuria;  unilateral  oedema  of  the  leg;  abscess  pointing 
near  Poupart's  ligament ;  with  constipation  on  the  left  side, 
and  involvement  of  the  receptacle  for  chyle  on  the  right  side. 

Calculous  Suppression  of  Urine  may  be  taken  as  a  condition  for 
which  nephrotomy  may  be  performed.  In  1880  Weir  advocated 
nephrotomy  for  calculous  suppression.  Bennett  Mayf  forcibly 
argues  in  favour  of  the  operation.  Bardenheuer,  according  to 
Weir,  has  removed  a  calculus  the  size  of  a  bean  from  the  ureter, 
and  four  others  from  the  pelvis  of  the  kidney.  Morris,  in  a  very 
suggestive  paperj  on  the  feasibility  of  removing  a  calculus  im- 
pacted in  the  ureter,  speaks  in  favour  of  the  proceeding.  No 
patient  should  be  permitted  to  die  of  calculous  suppression 
without  a  serious  attempt  to  discover  the  site  of  the  obstructing 
calculus.  If  low  down  in  the  ureter,  the  calculus  may  possibly 
be  removed  after  the  manner  suggested  by  Morris.  If  high  up, 
it   may  be  removed  by  nephro-lithotomy,  or  perhaps  by  pyelo- 

*  Trans,  A-mer.  Surg.  Ass.  ii.,  1885,  p.  518. 
+  Brit.  Med.  Journ.,  Mar.  8th,  18S4.      +  Amer.  Journ.  Med.  Sc,  Oct.,  1884. 


INDICATIONS  TO   OPERATE.  547 

nephrotomy.  If  its  site  cannot  be  discovered,  then  pyelotomy 
and  the  estabhshment  of  urinary  fistula  will  at  least  save  the 
patient's  life.  A  remarkable  example  of  the  value  of  nephrotomy 
for  total  suppression  of  urine  is  afforded  by  a  patient  of  Clement 
Lucas's,  from  whom  one  kidney  had  been  excised  four  months 
previously,  and  from  whose  remaining  kidney  a  large  calculus 
was  removed. 

Indications  to  Operate. — Nephrotomy  is  indicated  in  all  cases 
of  cystic  enlargement  where  puncture  has  failed.  More  precisel}^ 
it  is  called  for  in  cases  of  simple  cyst  where  tapping  has  been 
performed  five  or  six  times  without  effecting  a  cure.  Nephro- 
tomy as  an  original  operation  has,  according  to  Newman,  been 
performed  21  times  without  a  death  for  cases  of  hydronephrosis 
and  cystic  disease.  In  seven  of  these  cases  a  fistula  remained 
in  the  loin.  In  hydatid  disease,  if  one  tapping  does  not  kill  the 
parasite  or  check  the  growth  of  the  tumour,  nephrotom}'  may 
properly  be  performed.  In  hydro-nephrosis,  if  the  cyst  rapidly 
refills  after  two  or  three  tappings,  or  if  rupture  seems  imminent, 
nephrotomy  is  indicated.  In  every  case  suppuration  in  a  cyst 
is  an  indication  for  incision  and  drainage. 

In  all  cases  of  suppuration  in  and  around  the  kidney,  incision, 
with  evacuation  of  pus  and  drainage  of  the  abscess-sac,  is  indi- 
cated. Contra-indications  in  such  cases  are — firstly,  such  a 
condition  of  exhaustion  as  would  negative  any  serious  surgical 
exploit ;  and,  secondly,  a  diseased  condition  of  the  opposite 
kidney.  Wherever  operation  for  abscess  is  feasible,  nephrotomy 
ought  to  be  the  first  operation.  The  prime  object  is,  evacuation 
of  pus ;  secondary  objects  are,  diagnosis  of  the  actual  state  of 
affairs  and  determination  of  the  chances  which  nephrotomy 
provides  towards  cure,  and  preparation  of  the  kidney  and  tlie 
patient  for  the  major  operation  of  nephrectomy  where  mere 
incision  cannot  be  expected  to  be  curative.  Nephrectomy 
performed  in  the  first  place  as  an  operation  for  suppurative 
lesions  of  the  kidney,  is  not  so  successful  as  nephrectomy  per- 
formed as  an  operation  following  on  nephrotomy  and  drainage. 
The  patient  gains  strength  after  evacuation  of  an  abscess,  and 

36  * 


548  NEPHROTOMY. 

the  kidney  decreases  in  size ;  while  the  vascularity  of  the  organ 
and  the  density  of  its  adhesions  become  less  marked  after 
drainage. 

Rarely  is  operation  admissible  in  suppurative  nephritis  or 
pyelo-nephritis — in  uro-septic  or  surgical  kidney.  Scrofulous 
kidney  as  often  calls  for  excision  as  for  incision — at  least,  when 
the  abscesses  are  small  and  numerous. 

Before  performing  nephrotomy  it  is  advisable,  though  not 
necessary,  to  take  measures  for  ascertaining  the  condition  of 
the  other  kidney.  But  the  justifiability  of  the  operation  will 
be  the  urgency  of  the  disease.  Whether  the  opposite  kidney 
is  sound  or  not,  renal  or  peri-renal  abscess  which  is  endangering 
the  patient's  life  must  be  evacuated  if  the  general  condition  will 
warrant  operation. 

THE    OPERATION    OF    NEPHROTOMY. 

The  incision  is  the  same  as  that  already  described  as  suitable 
for  nephro-lithotomy,  and  the  structures  divided  are  identical. 
This  holds  good  for  suppurative  lesions,  if  there  is  no  great 
increase  in  size,  and  no  visible  tendency  to  point  through  the 
skin.  If  the  renal  enlargement  is  considerable,  the  incision  may 
be  carried  farther  forward  ;  and  redness,  swelling,  or  other 
indications  of  pointing,  must  be  taken  as  marking  the  best 
site  for  making  an  opening.  In  cases  of  non-suppurative  cystic 
enlargements,  the  ordinary  lumbar  incision  will  usually  be  best. 
True,  it  may  be  more  easy  to  make  the  opening  farther  towards 
the  front  in  cases  of  considerable  enlargement,  and  in  doing  so 
there  would  be  little  risk  of  entering  the  peritoneum.  But, 
looking  to  the  results  sought  to  be  attained — drainage  of  the 
cavity,  and  shrivelling  of  the  cyst — the  advantages  of  having 
the  kidney  or  its  remnants  fixed  well  behind  around  the  opening 
made,  and  of  having  a  dependent  opening  for  drainage,  weigh 
in  favour  of  the  ordinary  lumbar  incision. 

If  the  operation  is  for  hydatids,  simple  cyst,  or  hydro-nephrosis, 
there  may  be  no  peculiarity  in  the  tissues  traversed.  The  circum- 
renal  fat  will  be  thinner  than  normal,  being  either  spread  out  over 


THE  OPERATION.  549 

the  swelling  or  atrophied  from  pressure.  Adhesions  to  surround- 
ing tissues  may  be  present  in  hydatids.  A  portion  of  the  cyst- 
wall  is  denuded  of  overlying  fatty  tissue  to  an  extent  sufficient 
to  permit  of  its  being  brought  to  the  surface,  and  sutured  there 
after  being  opened.  An  excellent  mode  of  making  the  opening 
is,  to  push  a  Lister's  sinus  forceps  either  directly  through  the 
cyst-wall  or  through  a  small  opening  made  by  a  tenotome,  and 
dilate  the  opening  by  separating  the  blades.  As  the  contents 
flow  outwards,  the  cyst-wall  is  pulled  to  the  surface  by  means 
of  forceps  attached  to  the:  margin  of  the  opening.  Frequently 
it  will  be  found  impossible  to  pull  the  cyst-wall  quite  to  the 
level  of  the  skin  ;  then  fixation  of  the  opening  in  the  cyst  to 
tissues  as  near  to  the  surface  as  possible  may  be  tried,  or  the 
opening  may  be  left  to  itself  when  a  drainage  tube  has  been 
inserted.  In  every  case  evacuation  of  the  contents  is  to  be 
assisted  by  pressure  from  the  abdominal  aspect. 

In  operating  for  suppurative  lesions,  we  may  find  the  skin, 
muscles,  and  fasciae  traversed  by  the  incision  to  be  abnormally 
vascular  and  oedematous.  The  circumrenal  fat  may  be  hard, 
dense,  and  firmly  adherent ;  often  it  contains  numerous  small 
abscesses.  A  small  area  of  the  renal  capsule  is  exposed,  and 
through  this  the  largest  needle  of  an  aspirating  syringe  is 
pushed.  If  matter  is  struck,  it  is,  as  far  as  possible,  evacuated 
at  once ;  if  not,  the  needle  is  carefully  pushed  in  the  most 
likely  directions  till  purulent  fluid  is  met  with.  Along  the  side 
of  the  aspirating  needle  a  knife  or  dilating  forceps  is  pushed,  to 
enlarge  the  opening  sufficiently  to  admit  the  finger.  Curdy 
matter  which  will  not  run  through  a  tube  is  scooped  out  with 
the  finger,  and  the  cavity  thoroughly  explored.  If  openings 
into  other  abscess  cavities  are  found,  these  are  dilated,  if 
necessary,  and  their  contents  removed  :  if  this  is  impracticable, 
direct  openings  are  made  through  the  convex  surface.  In  each 
cavity,  and  reaching  to  the  bottom  of  it,  a  drainage  tube  is 
placed.  Finally,  through  the  tubes  the  abscess  cavities  are 
thoroughly  washed  out  by  irrigation  with  an  antiseptic  lotion. 
The  matter  found  in  renal  abscesses  is  often  very  offensive,  and 
frequent  irrigation  with  antiseptic  lotions  may  be  necessary. 


550  NEPHROTOMY. 

In  exploring  a  scrofulous  kidney,  the  septa  between  the 
abscesses  should  not  be  torn  or  cut  through,  as  they  are  often 
very  vascular.  The  finger  should  be  pushed  into  the  pelvis  if 
possible,  to  ascertain  whether  the  upper  end  of  the  ureter  is 
pervious. 

In  peri-nephritic  suppuration,  after  evacuating  the  pus,  the 
renal  surface  ought  to  be  carefully  examined,  to  ascertain 
whether  nephric  abscess  co-exists.  Such  an  abscess  must,  of 
course,  be  opened  and  drained. 

The  wound,  after  careful  disinfection  and  cleansing,  is  closed 
around  the  drainage  tube  or  tubes  in  the  ordinary  manner. 
Thick  rubber,  perforated  only  where  it  traverses  renal  tissue, 
makes  the  best  drainage  tube.  It  may  be  fixed  by  a  stitch  to 
the  skin.  Absorbent  dressings  are  fixed  over  the  wound  by 
means  of  an  abdominal  binder. 

The  progress  of  the  case  will  depend  on  the  nature  of  the 
operation.  In  hydatid  disease  the  cavity  will  probably  spon- 
taneously close  after  suppuration.  In  simple  cyst  primary 
closure  may  be  expected,  without  discharge  of  pus.  In  hydro- 
nephrosis, a  fistula  will  in  most  cases  be  left,  for  which  there  is 
no  cure  without  further  operation.  The  patient's  life  may  be 
made  fairly  comfortable  by  the  use  of  such  a  receptacle  as  that 
invented  by  Morris.  An  attempt  may  be  made  to  close  the 
fistula  by  a  plastic  operation,  but  it  is  not  often  successful. 
Nephrectomy  may  then  be  contemplated. 

Nephrotomy  for  abscess  is  frequently  a  curative  proceeding 
— more  frequently,  probably,  than  published  records  would  lead 
us  to  suppose.  Even  if  cure  do  not  follow,  no  harm  is  done, 
but  rather  good.  For  the  patient,  in  view  of  further  operative 
proceedings  by  nephrectomy,  has  been  tided  over  the  immediate 
danger  of  an  acute  illness,  and  has  gained  strength  ;  while  the 
kidney  is  diminished  in  size,  its  vessels  are  smaller,  its  tissue  is 
less  friable,  and  its  surroundings  are  more  tolerant  of  surgical 
interference. 


Nephrectomy. 

Nephrectomy  is  the  name  given  to  removal  of  the  kidney  by 
surgical  operation. 

History. — According  to  Heineke,""  Zambeccarius  was  the 
first  to  contemplate  the  operation  of  nephrectomy,  and  sought 
to  prove  its  feasibility  by  operations  on  dogs.  S.  Blancard 
successfully  extirpated  the  kidney  in  dogs  ;  and  several  surgeons 
who  saw  the  operation  considered  that  it  might  be  performed 
on  human  beings.  Rayer  condemned  the  operation  where  the 
kidney  was  inflamed  (as  in  calculous  nephritis),  because  then 
it  would  be  so  closely  adherent  to  the  peritoneum  that  it  could 
not  be  disturbed  without  injuring  that  membrane.  Blundell 
experimentally  performed  nephrectomy  on  animals. 

Nephrectomy  had  been  performed  unintentionally  several 
times  before  it  was  carried  out  deliberately  as  a  planned  opera- 
tion. In  i860,  Walcott  of  Milwaukee!  removed  a  cancerous 
kidney,  believing  it  to  be  a  hepatic  cyst.  Peaslee  and  one  or 
two  others  have  removed  renal  cysts,  believing  them  to  be 
ovarian  tumours.  Walcott's  case  lived  fifteen  days  ;  the  others 
succumbed  more  quickly.  The  first  planned  operation  was 
performed  by  Simon  of  Heidelberg,  in  April,  i86g.  Before 
operating  on  the  human  subject,  he  had  experimented  on 
animals.  His  operation  was  performed  for  incurable  fistula 
of  the  ureter,  and  his  patient — a  lady — made  an  excellent 
recovery.  Since  1869,  the  operation  has  been  performed  at 
least  300  times,  and  with  a  steadily  decreasing  mortality. 

Conditions  for  which  the  Operation  may  be  Performed. — These  may 
be  classified  as  follows  : 

(i)  The  same  class  of  diseases  as  call  for  nephrotomy  when 
this  operation  is  not  likely  to  succeed,  or  has  already  been  tried 
and  failed. 

(2)  New  growths  of  the  kidney. 

(3)  Ureteral  and  renal  fistulae. 

*  Von  Pitha  and  Billroth's  Surgery,     f  Phih.  Med.  and  Surg.  Rep,,  1861,  p.  126. 


552  NEPHRECTOMY. 

(4)  Serious  injury  to  the  kidney,  with  hasmorrhage,  urinary 
infiltration,  or  destructive  suppuration. 

(5)  Disease  or  degeneration  in  movable  kidney. 

(i)  In  the  category  of  failures  after  nephrotomy  we  may 
include  all  cases  where  a  renal  fistula  is  left.  This  may  happen 
after  incision  for  any  cystic  or  purulent  collection,  in  simple 
hydatid  cysts,  in  hydro-nephrosis  or  pyo-nephrosis,  and  in  renal 
suppurations  of  all  sorts.  The  original  disease  ma}^  be  cured; 
the  fistula  is  an  accidental  complication,  which  has  to  be  raised 
to  the  dignity  of  a  separate  disease,  and  counted  as  a  special 
indication  for  operation. 

By  far  the  most  important  class  of  failures  after  nephrotomy 
which  may  demand  nephrectomy  is  supplied  by  suppurative 
lesions  of  the  kidney.  On  account  of  multiplicit}^  of  abscesses, 
it  may  be  impossible  to  open  and  drain  them  all ;  a  large  abscess 
may  have  been  opened,  and  several  small  ones  may  have  been 
overlooked  ;  the  abscess-sacs  may  be  very  slow  to  collapse,  and 
the  patient's  strength  may  be  ebbing  away  from  prolonged  sup- 
puration ;  these  and  similar  considerations  may  suggest  the 
major  operation.  Again,  in  some  cases  nephrotom}^  is  deliber- 
ately performed  as  a  temporary  measure,  intended  to  effect 
improvement  in  the  local  as  well  as  in  the  general  condition, 
before  nephrectomy  is  undertaken.  Bruce  Clarke,  Lucas,  and 
others  have  specially  insisted  on  the  value  of  this  measure. 

Among  diseases  ordinarily  amenable  to  nephrotomy,  a  certain 
number  will  be  met  with  where  this  operation  would  evidently 
prove  futile,  and  where  nephrectomy  gives  the  only  chance  of 
recovery.  Scrofulous  kidney  would  perhaps  furnish  the  greatest 
number  of  examples  under  this  head.  The  organ  may  be 
riddled  with  abscesses,  which  can  neither  be  evacuated  nor 
drained  without  causing  great  haemorrhage  or  seriously  damaging 
the  renal  structure.  In  this  case,  a  complete  nephrotomy  would 
result  in  chopping  the  kidney  into  fragments,  and  would  be  a 
more  grave  affair  than  nephrectom3\  Any  variety  of  extensive 
suppuration  that  is  not  localised  in  one  district  demands  nephrec- 
tomy.    Calculous  nephritis  may  be  of  this  nature.     Very  exten- 


NEW   GROWTHS.  553 

sive  suppuration  has  followed  injur}'  to  the  kidney  :  Von  Bruns, 
under  these  circumstances,  had  on  one  occasion  to  remove  the 
organ. 

(2)  New  growths  of  the  kidney  may  be  another  indication 
for  nephrectomy.  The  varieties  of  new  growth  are  classified  by 
Paul*  as  follows  : 

Of  Congenital  Origin  : — 

i  Round-celled. 
Fibro-sarcoma. 
Striped  Myo-sarcoma  (Rhabdo-myoma). 
\  Adeno-sarcoma. 

Dermoid  tumours. 

Of  Adult  Origin  : — 

Cysts. 

Cavernous  tumours. 

Sarcoma. 

Adenoma 


{ 


Cystic. 
Tubular. 


[  Pelvic,  like  bladder. 

Carcinoma:     <  ^^,       ■,   1        (  Cystic. 
)  Glandular:  ]  rj.-'  ■,     , 
(  (  Tubular. 

Many  other  classifications  have  been  offered,  notably  the 
exhaustive  one  of  Newman;  but  the  above,  prepared  after 
special  opportunities  for  study,  may  be  accepted  as  trustworthy. 

Cystic  tumours  of  the  kidney  have  already  been  dealt  with, 
under  puncture  and  nephrotomy.  There  remain  for  consider- 
ation the  solid  growths  ;  and  these,  as  will  be  seen  from  the 
classification,  are  mostly  of  a  malignant  nature.  Sarcoma, 
both  of  congenital  and  of  adult  origin,  is  by  far  the  most 
important ;  and  carcinoma  comes  next  in  importance  and  in 
frequency.  In  a  most  valuable  study  of  Primary  Malignant 
Disease  of  the  Kidneys,  Mingest  found  that  of  63  cases,  30 
were  sarcomata,  30  carcinomata  (21  encephaloid — probably 
most  of  them  really  sarcomata),  i  adenoma,  and  i  fibro-cystic. 
It  is  clear,  however,   that  different  men  reporting  their  cases 

•  Brit.  Med.  Joimi.,  Jan.  12th,  1884. 
t  Journ.  Amer.  Med.  Assn.,  June  6th,  1885,  et  seq. 


554  NEPHRECTOMY. 

have  followed  different  classifications,  and  no  exact  conclusions 
can  be  drawn  from  the  nomenclature  adopted.  Billroth  removed 
a  papillomatous  growth.  Adenoma  is,  in  one  case,  given  as  the 
name  of  the  tumour  for  which  the  kidney  was  removed.  Further 
consideration  of  minor  varieties  of  new  growths  may  be  dis- 
missed ;  our  purpose  here  will  be  fulfilled  by  an  account  of 
primary  malignant  disease,  as  represented  by  sarcoma  and 
carcinoma.  Secondary  malignant  disease  does  not  concern  the 
operating  surgeon. 

Malignant  growths  of  the  kidney  show  a  curious  predilection 
for  youth  and  for  old  age  ;  they  are  least  common  during  adult 
life.  Congenitally,  sarcoma  is  the  form  of  malignant  disease 
usually  met  with  :  carcinoma,  though  not  unknown,  is,  as  Ebstein 
states,  very  rare  in  infancy  and  childhood  ;  it  is  more  common  in 
old  age.  Traumatic  irritation,  as  by  calculus,  is  now  admitted 
to  be  a  contributive  cause  of  renal  cancer.  The  disease  occurs 
with  equal  frequency  in  both  kidneys  ;  very  rarely  does  it  exist 
in  both  organs  at  the  same  time. 

The  tumour  frequently  attains  to  enormous  dimensions ;  and 
this  is  particularly  true  of  growths  occurring  in  children.  Roberts 
records  an  example  found  in  a  child  of  six,  where  the  tumour 
weighed  31  lbs.  In  its  growth  the  tumour  extends  into  the 
pelvis,  often  blocking  the  ureter,  and  sometimes  passing  down  it 
for  a  considerable  distance.  The  renal  vein  soon  becomes  in- 
volved ;  and  through  it  the  cancer  may  grow  inwards  to  the  vena 
cava,  thus  providing  a  focus  from  which  infarcts  may  be  carried 
into  lungs  or  liver.  The  retro-peritoneal  glands  escape  with 
curious  frequency.  Ebstein  says  that  secondary  deposits  are 
found  in  more  than  half  the  cases  that  die  of  the  disease.  Local 
extension  into  peri-renal  tissue  is  not  very  common  ;  and  invasion 
of  neighbouring  structures — vertebrae,  ribs,  intestines,  stomach — 
though  described,  is  even  more  rare.  I  have  seen  a  case  of 
primary  cancer  of  the  kidney,  where  the  omentum  alone  was 
attacked  by  local  extension  of  the  disease.  Though  malignant 
disease  of  the  lower  urinary  tract,  in  testis,  prostate,  or 
bladder,  frequently  infects  the  kidney,  the  reverse  is  practically 
unknown. 


SYMPTOMS   OF  RENAL    CANCER.  555 

Symptoms. — Roberts  says :  "The  distinctive  symptoms  of  can- 
cer of  the  kidney  are,  tumour  in  the  abdomen  and  haematuria. 
In  every  case  in  which  it  was  the  determining  cause  of  death, 
either  one  or  both  were  present."  If  this  is  not  accurately  true, 
it  is  certainly  very  approximately  so.  Minges  found  a  tumour 
absent  only  three  times  in  103  cases,  and  in  two  of  these  cases  a 
tumour  was  not  discovered  because  it  was  not  carefuU}^  looked 
for.  A  tumour  is  always  present  in  children,  and  frequently  it 
is  of  enormous  size.  Haematuria  is  found  in  about  half  the 
cases,  and  in  a  far  greater  proportion  of  those  which  claim  origin 
from  injury.  It  is  usually  irregularly  intermittent,  and  occurs  in 
varying  amount  at  all  stages  of  the  disease.  Occasionally  the 
blood  is  very  abundant,  forming  clots  in  the  ureter  or  bladder, 
and  causing  renal  colic  or  vesical  tenesmus.  The  urine  in  the 
intervals  of  bleeding  is  usually  normal,  though  pus-cells  and 
tube-casts  are  sometimes  found. 

Pain,  as  a  symptom  of  malignant  disease  of  the  kidneys,  is 
found  in  most,  though  not  in  all,  cases.  It  is  situated  chiefly  in 
the  loin  and  abdomen,  but  radiates  widely  in  all  directions 
around  the  back  and  shoulders,  and  down  the  front  and  back  of 
the  thigh. 

The  physical  signs  are,  shortly :  a  solid  tumour  situated  in 
the  loin,  growing  forwards,  and  not  at  all  bulging  backwards  ; 
rounded  and  smooth  where  palpable;  resisting  movements  on 
pressure,  and  not  descending  on  inspiration  ;  dull  on  percussion 
from  the  spine  forwards,  except  perhaps  along  a  vertical  line  in 
front  where  it  is  crossed  by  large  intestine.  It  is  characteristic 
of  renal  tumours,  that  when  the  lumbar  hollow  is  filled  up,  all 
further  development  is  forwards.  Renal  tumours  may  be  diag- 
nosed from  hepatic  and  splenic  enlargements  by  the  fact  that  they 
are  rounded  on  all  sides  where  exposed  to  the  examining  fingers. 
There  is  no  notch  or  sharp  edge  anywhere.  Fixation  is  said  to 
be  a  characteristic  of  renal  growths :  they  impart  to  the  feel  a 
peculiar  sense  of  resistance  when  attempts  are  made  to  move 
them  in  any  direction.  There  are,  however,  exceptions  to  this 
rule.  There  is  no  resonance  in  the  flank.  The  large  intestine 
crossing  in   front  of  the  tumour  is,   when  present,  a  valuable 


556  NEPHRECTOMY. 

diagnostic  sign.  The  ascending  colon  usuall}^  passes  over  the 
front  and  inner  side  of  the  growth  ;  the  descending  colon  passes 
in  front,  and  a  little  to  the  outer  side.  If  distended,  the  colon 
may  be  detected  by  its  resonant  note  on  percussion ;  if  empty, 
it  may  be  felt  and  rolled  about  by  the  fingers. 

Renal  growths  are  liable  to  be  confounded  with  hepatic 
enlargements  on  the  right  side,  splenic  enlargements  on  the  left, 
and  also  with  faecal  accumulations  and  tumours  of  the  ovary. 
Hepatic  tumours  have  no  bowel  in  front,  and  the  liver  margin 
can  often  be  felt.  A  space  into  which  the  fingers  may  be  pushed 
is  usually  left  between  the  upper  extremity  of  a  renal  growth 
and  the  edge  of  the  ribs.  An  enlarged  spleen  has  no  bowel  in 
front ;  it  has  a  well-defined  edge,  in  some  cases  notched.  Faecal 
accumulation  onl}'  requires  to  be  mentioned  as  a  possible  source 
of  error.  Cystic  enlargements  of  the  kidney  are  more  likely  to 
be  mistaken  for  ovarian  tumours  than  solid  growths. 

{3)  Urinary  fistulae  connected  with  ureter  or  kidney  may  be 
an  indication  for  nephrectom3\  Simon's  operation  was,  as 
already  remarked,  performed  for  ureteral  fistula.  In  most  cases 
ureteral  fistula  is  a  result  of  an  operation  wound.  It  may  be 
produced  b}'  sloughing  after  a  difficult  labour.  The  operation 
of  nephrectomy  has  been  performed  at  least  eight  times  for 
urinary  fistula. 

Renal  fistula  may  be  produced  by  wounds  of,  or  by  disease 
in,  the  kidney.  In  the  great  majority  of  cases,  it  opens  in  the 
loin.  But  rare  examples  are  found  of  renal  fistula  opening  into 
various  parts  of  the  intestines,  into  the  stomach,  and  into  the 
lung.  Renal  fistula  opening  into  the  peritoneum  is  rapidly 
fatal,  if  not  treated. 

The  diagnosis  of  these  conditions  requires  no  description. 

(4)  Cases  of  grave  injury  to  the  kidney,  involving  rupture  of 
the  organ  with  free  bleeding,  may  call  for  nephrectomy  as  the 
onl}^  chance  of  saving  life.  The  danger  is  not  so  much  from  the 
amount  of  bleeding,  as  from  the  clotting  of  the  blood  in  the 
bladder,  with  resulting  inability  to  pass  urine.  Rawdon*  of 
Liverpool  performed  nephrectomy  in  a  case  of  this  sort,  and 
*  Lancet,  May  26,  1883. 


MORTALITY.  557 

would  have  saved  his  patient's  Hfe,  had  it  not  been  that  decom- 
position of  blood  in  the  bladder  set  up  cystitis  and  suppurative 
nephritis  of  the  opposite  kidney,  and  this  in  spite  of  C3^stotomy 
performed  four  days  after  the  nephrectomy. 

In  cases  of  urinary  infiltration,  with  destructive  suppuration, 
nephrectomy  may  be  called  for.  But  the  major  operation  will, 
in  most  cases,  be  adopted  only  as  a  sequence  to  lumbar  incision 
and  drainage.  West,  Bennett  May,  Barker,  Weir,  and  others 
have  published  cases  of  this  sort. 

(5)  An  account  has  already  been  given  of  the  diseases  or 
degenerations  which  are  liable  to  attack  movable  kidney.  Here 
the  indication  to  operate  will  usually  be  pain  or  enlargement 
accompanying  the  mobility ;  and  in  most  cases  the  decision  to 
proceed  to  removal  will  only  be  come  to  after  exposure  and 
examination  of  the  organ. 

Mortality  and  Appreciation  of  Nephrectomy. — The  statistics  of 
nephrectomy  have  been  collected  by  Harris,  Billroth,  Gross, 
Weir,  Baum,  Minges,  and  others.  The  general  mortality  was 
given  by  Harris,*"  in  1882,  as  45  per  cent. ;  by  Billroth,!  in  1884, 
as  47  per  cent.;  by  Weir,|  in  152  cases,  as  50  per  cent.;  and 
by  Gross, §  in  1885,  in  233  cases,  as  44.6  per  cent.  The  latest 
statistics: — of  Baum,||  adding  72  cases  up  to  Februar}^,  1884, 
giving  a  mortality  of  over  50  per  cent. ;  and  of  Minges,^  giving 

60  cases  of  operation  for  primary  malignant  disease,  with  46 
deaths, — show  little  improvement.  The  most  recent  and  most 
complete  statistics  are  those  of  Newman. ^'"^'  Nephrectomy  has 
been  performed  for  hydronephrosis  and  cystic  disease  46  times, 
with  18  deaths  ;  for  suppurative  disease  without  calculus  54 
times,  with   18  deaths;    for  suppurative  disease  with  calculus 

61  times,  with  22  deaths ;  for  tubercular  disease  33  times,  with 
12  deaths;  and  for  tumours  of  various  sorts  74  times,  with  24 

*  Amey.  Jouvn.  Med.  Sc,  July,  1882.     f  Wien.  mcd.  Woch.,  1884,  Nos.  23,  24,  25. 

\  New  York  Med.  Jotmu,  Dec.  27th,  1884. 

§  Amer.  Jouvn.  Med.  Sc.,  July,  18S5,       |]  Phila.  Med.  Times,  Feb.  21st,  1885. 

•1   Journ.  Amer.  Med.  Ass.,  June  6th  and  13th,  1885. 

**  Surg.  Diseases  0/  Kidney,     1888. 


658  NEPHRECTOMY. 

deaths.  This  gives  a  total  of  268  operations,  with  94  deaths. 
In  Newman's  Hst  are  also  included  30  nephrectomies  for  movable 
kidney,  with  g  deaths,  and  27  for  traumatic  lesions,  with  8  deaths. 
The  total  mortality  is  35.2  per  cent.  The  results  of  individual 
operators  of  experience  are  more  favourable,  but  not  strikingly 
so.  Under  the  most  advantageous  circumstances,  a  general 
primar}^  mortality  may  be  expected,  in  all  cases  of  nephrectomy, 
of  something  under  40  per  cent. 

In  malignant  disease  recurrence  takes  place  in  a  proportion 
of  40  per  cent.,  according  to  Martin  of  Berlin.  Gross  estimates 
that  recurrence  takes  place  in  a  third  of  all  the  cases,  and  that 
the  average  duration  of  life  is  two  years:  of  13  operations  on 
children,  only  4  recovered  ;  and  all  of  these  died  later.  Some 
three  or  four  cases  of  permanent  recovery  in  children,  after 
nephrectomy  for  sarcoma,  have  since  been  recorded;  so  that 
the  prospect  may  not  be  as  hopeless  as  Gross  left  it. 

The  results  vary  according  to  the  nature  of  the  disease  for 
which  operation  is  performed.  The  worst  results  are  got  for 
malignant  disease  —  nearly  70  per  cent.  die.  For  strumous 
kidney,  the  mortality  is  about  36  per  cent.  Here  it  was  found 
that  previous  nephrotomy  did  not  prove  advantageous.  For 
suppurative  lesions,  Gross  found  that  nephrectomy,  without 
antecedent  nephrotomy,  gave  a  death-rate  of  nearly  50  per 
cent. ;  while  nephrotomy  gave  a  death-rate  under  30  per  cent. 
Bolz  and  Weir  give  not  very  different  results. 

Indications  and  Contra-indications. — ^With  results  such  as  those 
described,  it  is  not  surprising  that  nephrectomy  should  be  looked 
upon  with  some  degree  of  disfavour.  No  doubt  the  mortality 
has  been  increased  by  a  selection  of  unfavourable  cases,  or  by 
delaying  the  operation  too  long.  Under  the  most  favourable 
circumstances,  however,  it  may  be  taken  for  granted  that  the 
mortality  of  nephrectomy  will  always  be  high.  In  favour  of  the 
operation,  even  thus  loaded  with  a  terrible  death-rate,  it  may 
be  urged,  that  it  is  performed  for  a  certainly  fatal  disease;  a 
complete  success  is  a  life  saved ;  a  failure  is  simply  an  acceler- 
ated dying. 


INDICATIONS.  559 

For  sarcoma  and  cancer,  the  position  of  the  operation  would 
probably  be  as  follows  :  In  all  cases  where  the  disease  has  been 
known  to  exist  for  some  months,  where  the  growth  is  large,  and 
particularly  if  it  is  firmly  adherent  in  the  loin,  no  operation  is 
advisable.  In  children,  unless  the  growth  is  small,  the  patient 
healthy  and  not  less  than  four  or  five  years  of  age,  no  operation 
is  to  be  thought  of.  In  a  word,  for  malignant  disease,  nephrec- 
tomy is  a  justifiable  procedure  only  in  a  very  few  specially 
selected  cases.  It  is  right  to  add  that,  for  children,  Gross 
forbids  operation  altogether. 

In  h3'dro-nephrosis,  as  in  cystic  disease,  removal  ought  not 
to  be  undertaken  till  incision  has  been  tried  and  has  failed. 
Billroth  considers  that  for  hydro-nephrosis,  nephrectomy  ought 
never  to  be  performed.  In  a  third  of  the  cases,  removal  has 
been  carried  out  after  mistaking  the  disease  for  ovarian  cystoma: 
naturally,  the  mortality  is  much  greater  than  after  incision.  If 
fistula  remains,  this  may  be  palliated  or  treated  later  on  with 
more  chance  of  success  by  nephrectomy. 

In  suppurative  lesions,  the  question  of  excision  as  against 
incision  will  depend — firstly,  on  the  condition  of  the  patient ; 
and,  secondly,  on  the  state  of  the  organ.  It  may  be  laid  dow^n 
as  a  rule,  never  to  be  departed  from,  that  no  suppurating  kidney 
should  be  removed  without  first  making  a  careful  examination 
through  an  exploratory  incision  into  its  substance.  Also,  the 
major  operation  should  not  be  performed  if  the  patient  is  very 
weak.  The  mortality  of  nephrotomy  is  less  than  that  of  ne- 
phrectomy, but  not  so  much  less  as  might  be  expected  :  the 
per-centage  of  recoveries  in  favour  of  the  former  operation  is 
only  twenty-five.  Still,  this  is  decisive  where  nephrotomy  is 
likely  to  be  curative.  But  certain  cases  will  evidently  not  be 
cured  by  nephrotomy :  in  these,  it  may  even  be  doubtful 
whether  traumatic  interference  will  not  be  positively  harmful ; 
and  it  may  appear  that  the  patient,  on  the  operating  table,  is 
in  a  condition  as  favoural^le  as  he  is  ever  likely  to  be  for  opera- 
tion. Such  cases  will  usually  be  scrofulous ;  and,  as  a  matter 
of  fact,  the  mortality  after  nephrotomy  for  scrofulous  kidney  is 
just  as  great  as  after  nephrectomy.     In  every  case  where  ne- 


560  NEPHRECTOMY. 

phrotomy  presents  a  fair  chance  of  cure,  or  even  of  amelioration, 
it  should  be  selected ;  where  nephrotomy  is  out  of  court,  and 
the  patient  is  likely  to  bear  it,  nephrectomy  may  be  performed. 

For  wounds  in  the  kidney  and  their  consequences,  nephrec- 
tomy has  been  performed  by  Brandt,  Marvand,  Cartwright, 
Rawdon,  and  Bruns — five  times,  with  two  deaths.  If  death 
seems  to  be  imminent  from  haemorrhage,  and  after  exploratory 
incision  it  is  found  to  be  impossible  to  check  the  bleeding,  then 
nephrectomy  ought  to  be  performed.  Clots  in  the  ureter  may 
cause  suppression  of  urine ;  in  the  bladder,  they  may  prevent 
the  discharge  of  urine,  or  set  up  cystitis :  here  also,  if  bleeding 
cannot  be  checked,  and  life  is  being  endangered,  nephrectomy 
is  indicated.  Where  suppuration,  with  extravasation  of  urine, 
follows  rupture  of  the  kidney,  incision  or  removal  is  indicated, 
according  to  the  gravity  of  the  condition  and  the  state  of  the 
patient. 

Urinary  fistula,  renal  or  ureteral,  if  it  causes  great  discomfort 
and  prevents  the  patient  from  following  a  necessary  occupation, 
may  be  an  indication  for  nephrectomy.  Simon,  Archer,  Boeckel 
and  others,  have  operated  for  ureteral  fistula  caused  by  acci- 
dental wound  inflicted  during  hysterectoni}'.  The  greatest 
number  of  operations  have  been  performed  for  renal  fistula 
left  after  nephrotomy,  and  here  the  results  have  been  most 
favourable. 

Methods  of  Ascertaining  the  Condition  of  the  othev  Kidney. — Before 
proceeding  to  remove  one  kidney,  it  is  well  to  ascertain  as  ac- 
curately as  possible  whether  the  other  kidney  is  sound  ;  or,  in 
fact,  whether  it  exists.  Though  it  has  been  estimated  that  the 
kidney  is  solitary  only  once  in  4,000  cases,  it  has  been  the  un- 
fortunate lot  of  one  surgeon  to  remove  such  an  organ.  This 
was^the  remarkable  case  of  Polk,*'  in  which  a  displaced  kidne}^ 
lying  on  the  left  side  above  Poupart's  ligament,  was  removed, 
and  found,  at  the  post-mortem  examination  eleven  days  later, 
to  be  the  only  kidney.  In  cases  of  suppurative  disease  where 
nephrectomy  is  contemplated,  the  importance  of  ascertaining 
*  NeiD  York  Med.  Joxirn,,  Feb.  17th,  1S83. 


EXPLORING   THE    URETERS.  561 

the  functional  capacity  of  the  organ  to  be  left  can  scarcely 
be  over-estimated.  It  is  not  surprising,  therefore,  that  many 
devices  with  this  object  in  view  have  been  introduced  ;  and  it 
is,  perhaps,  no  less  surprising,  considering  the  inherent  difficulty 
of  the  procedure,  that  none  of  these  devices  is  entirely  satis- 
factory. 

Tuchmann*  invented  a  compressor,  something  like  a  litho- 
trite,  for  the  ureter,  which  he  improved  in  1880.  Hegarf  pro- 
posed temporary  ligature  of  one  ureter  through  the  vagina. 

Simon,  I  in  1875,  practised  direct  catheterisation  of  ureters 
through  the  dilated  urethra  in  the  female  ;  but  after  much  prac- 
tice, he  attained  to  only  a  qualified  success.  In  1876  Griinfeld  j 
used  Simon's  method  with  the  help  of  an  endoscope. 

Pawlik  of  Vienna  ||  claims  to  have  been  the  first  to  sound 
the  ureters  in  the  female  without  dilating  the  urethra.  Using  as 
guides  certain  folds  in  the  vaginal  wall,  he  has  succeeded  in 
passing  hollow  sounds  into  the  ureters  of  the  female  150  times 
in  the  dead  subject,  and  50  times  in  the  living.  His  method 
has  not  generally  been  adopted,  in  this  country  at  least. 

Silbermann  *;  sought  to  compress  the  ureter  by  small  rubber 
bags,  filled  with  quicksilver,  introduced  through  a  large  silver 
catheter.  Newman  of  Glasgow,  in  cases  of  his  own,  and  in  one 
of  Dr.  McCall  Anderson's,  has  used  Silbermann's  method  with 
success.  But  Newman  has  introduced  a  plan  of  his  own,  in 
which  sight,  with  the  help  of  an  electric  lamp  in  the  bladder,  is 
called  in  to  help  in  the  passing  of  the  catheter  into  the  ureter. 

Sands  recommends  the  insertion  of  the  hand  into  the  rectum, 
and  compression  of  the  ureters  by  the  fingers. 

Gliick**  recommends  a  proceeding  even  more  serious ;  namely, 
compression  of  the  ureter  by  forceps  through  a  lumbar  incision. 
The  opposite  kidney  is  supposed  to  be  sound  if  iodide  of  soda, 
or  ferro-cyanidc  of  potassium,  administered  to  the  patient,  is 

*  Wien.  med  IVoch.,  1874,  No.  20.         t  Operat.  Gynnk.,  1874,  p.  456. 

X  "  Uber  die  Methoden  die  Weibliche  Urinblase,"  &c., 

Samml.  hlin.  Vortr.,  No.  38. 

^Wein.med.Presse,  i876,Nos.27,  28.    ||  See  letter  in  G/as^.  M^cf.  Joxm.,  July,  1885. 
II  Berl.  klin.  Woch.,  No.  34,  1883.       **  Ceniralbl.  f.  Chir.,  Dec.  loth,  1881. 

37 


562  NEPHRECTOMY. 

found  in  the  urine  secreted  by  the  other  kidney.     But  a  kidney 
advanced  in  disease  might  elude  this  test. 

Polk*  has  devised  a  clamp  for  compressing  the  ureter,  one 
blade  being  inside  the  bladder  and  the  other  in  the  rectum. 
The  bladder  being  washed  out,  the  urine  secreted  by  the  other 
kidney  can  be  got  in  a  fairly  pure  state  and  examined. 

Davy's  rectal  lever  has  been  uj^ed,  with  somewhat  uncertain 
results,  to  compress  the  ureter  as  it  crosses  the  brim  of  the 
pelvis.  On  the  right  side  it  can  be  employed  only  when  there 
is  a  well-developed  mesentery  to  the  rectum. 

Fen  wick's  f  ingenious  apparatus  for  performing  suction  of  the 
ureters  in  the  male  promises  to  be  valuable  ;  but  it  has  scarcely 
been  more  than  tried.  \ 

On  one  occasion,  while  removing  papillomatous  growths 
from  the  female  bladder,  I  was  struck  with  the  ease  with  which 
I  could  detect  and  reach  the  orifices  of  the  ureters.  To  enter 
the  female  bladder,  I  now  always  incise  the  outer  urethra,  and 
dilate  the  inner  urethra  and  the  neck  of  the  bladder.  The 
additional  freedom  in  exploring  the  bladder  so  afforded  is  much 
greater  than  would  be  supposed  :  I  feel  sure  that  little  difficulty 
would  be  experienced  in  finding  the  orifices  of  the  ureters,  and  in 
catheterising  them,  by  this  method.  It  is  easy  enough  on  the 
dead  body.  Three  or  four  catgut  sutures  give  primary  healing, 
and  no  incontinence  is  left.  Probably  some  modification  of 
Polk's  plan  will  be  found  most  suitable  for  the  male. 

Our  confidence  must  rest  mainly  on  the  characters  of  the 
urine  as  a  whole,  and  on  the  condition  of  the  patient.  The 
quantit}^  of  urine,  its  per-centage  of  solids  and  especially  of 
urea,  and  the  presence  of  no  more  albumen  than  might  be 
accounted  for  by  the  pus  in  the  urine,  must  be  our  chief  data 
for  guidance.  Any  symptoms  of  ursemic  poisoning,  of  course, 
negative  the  operation. 

Abdominal  section  is  valuable  as  a  means  of  ascertaining  the 
*  New  York  Med.  Journ.,  Feb.  17th,  18S3. 
t  Lancet,  Sept.  i8th,  1886. 

J  For  an  exhaustive  consideration  of  the  methods  of  exploring  the  ureters 
in  the  female,  see  M.  D.  Schultz,  Nouv.  Arch.  d'Obsfet.  et  de  Gyne'c,  ii.,  5,  p.  205. 


THE   OPERATION.  563 

condition  of  the  other  kidney ;  but  its  true  position  is  rather 
as  an  alternative  to  lumbar  nephrectomy  which  secures  this 
additional  advantage,  than  as  a  mere  method  of  diagnosis. 

THE    OPERATION. 

The  kidney  may  be  removed  in  two  ways : 

(i)  By  incision  through  the  loin — Lumbar  nephrectomy. 
(2)  By  incision  through  the  parietes — Abdominal  nephrec- 
tomy. 

Lmnhav  Nephrectomy. — Several  varieties  of  incision  are  recom- 
mended. Morris  recommends  "  a  transverse  or  slightly  oblique 
incision,  made  somewhat  nearer  the  last  rib  than  in  colotomy  ; 
with  this  should  be  conjoined  a  second  incision,  running  verti- 
cally downwards  from  the  first,  and  starting  from  it  about  one 
inch  in  front  of  its  posterior  extremity."  The  special  advantage 
of  the  vertical  incision  is,  that  it  affords  increased  facility  for 
passing  the  ligature  round  the  pedicle.  Weir*'  made  use  of  a 
lumbar  vertical  incision  three  inches  from  the  spine,  just  below 
the  twelfth  rib,  and  extending  to  the  crest  of  the  ilium ;  and  a 
second  incision,  transverse,  varying  in  length  according  to 
requirements,  and  running  from  near  the  top  of  the  vertical 
incision  along  the  edge  of  the  ribs.  Simon's  original  incision 
was  a  vertical  one  ;  but  in  his  case  the  kidney  was  not  enlarged. 
Lucas  t  recommends  an  oblique  incision,  as  for  colotom}^, 
supplemented  by  a  vertical  one  carried  along  the  outer  edge  of 
the  quadratus,  and  extending  from  the  last  rib  to  the  iliac  crest. 
Klineberger  used  a  curved  incision,  the  convexity  of  which  was 
upwards  and  outwards.  Thornton,  ]:  in  a  discussion  on  Dr. 
Walter's  case  of  nephrectomy  for  cystic  tumour  of  a  floating 
kidney,  thought  that  the  operation  of  the  future  would  be  a 
vertical  incision,  farther  out  than  Langenbuch's  through  the 
linea  semilunaris;  not  entering  the  peritoneum,  but  pushing  it, 
with  the  colon,  inwards.  Other  varieties  of  incision  have  been 
described. 

*  New  York  Med.  Journ. ,  Dec.  27th,  1S84.     f  Brit.  Med.  Journ.,  ii. ,  18S3,  p.  61 1. 

\  Brit.  Med.  Journ.,  ii.,  1S83,  p.  615. 

37  * 


564  NEPHRECTOMY. 

The  lines  of  incision  should  be  determined  by  the  condition  of 
the  organ  to  be  removed.  A  healthy  kidney,  or  one  but  slightly 
enlarged  and  not  adherent,  may  be  removed  through  a  simple 
oblique  incision  made  between  the  ribs  and  the  iliac  crest.  The 
upper  extremity  should  be  at  least  an  inch  distant  from  the  last 
rib  :  the  lower  extremity  may  be  carried  close  to  the  crest  of  the 
ilium  ;  if  the  costo-iliac  space  is  small,  the  line  of  incision  may 
be  curved  forwards  some  distance. 

If  the  kidney  is  of  large  size,  or  if  it  is  fixed  by  adhesions, 
more  space  is  required  both  for  its  removal  and  for  performing 
the  necessary  manipulations  in  enucleating  it.  In  every  case, 
the  operation  may  be  begun  by  the  oblique  incision.  Through 
it  the  condition  of  the  kidney  may  be  ascertained,  and,  in  cases 
of  suppuration,  a  decision  come  to  as  to  the  advisability  of 
giving  nephrotomy  a  trial ;  while,  if  the  kidney  is  to  be  removed, 
the  best  mode  of  enlarging  the  incision  will  be  more  accurately 
judged  after  seeing  the  amount  of  space  provided  by  the  oblique 
incision.  Some  form  of  transverse  incision,  starting  near  the 
lower  extremity  of  the  oblique  one  and  carried  towards  the 
middle  line  as  far  as  may  seem  expedient,  will  usually  be  found 
the  best.  It  is  made  by  the  scissors  cutting  through  the 
parietes  at  one  stroke,  and  guided  by  the  forefinger,  which  is 
pushed  forwards  through  the  cellular  tissue,  and  keeps  the  peri- 
toneum out  of  the  way.  The  incision  may  be  carried  forward  to 
any  distance  desired,  the  peritoneum  being  carefully  elevated 
from  the  kidney  surface,  and  pushed  inwards. 

The  actual  lines  of  incision  are  not  of  supreme  importance. 
Any  incision  which  gives  plenty  of  room,  and  does  not  involve 
entering  the  peritoneal  cavity,  may  be  adopted.  The  incision 
described  is  that  which  I  have  found  most  suitable. 

The  incisions  being  made,  and  all  bleeding  points  having 
been  secured,  the  kjdney  is  separated  from  its  connections.  If 
there  has  been  no  inflammation,  this  will  be  found  an  easy  pro- 
ceeding ;  the  forefinger  of  one  hand,  carried  close  to  its  capsule, 
readily  enucleating  the  organ  from  its  fatty  bed.  But  if  there 
has  been  much  inflammation,  the  cellulo-fatty  tissue  may  be 
very  dense  and  very  adherent,  and  enucleation  may  prove  very 


THE  OPERATION.  665 

difficult.     In  some  cases,  enucleation  is  simply  impossible  with- 
out the  use  of  a  cutting  instrument — scissors  being  best  for  this 
purpose.     An  attempt  may  be  made  to  enucleate  the  kidney 
from  its  capsule,  leaving    the  capsule  behind  ;    but  this  also, 
if  there  has  been  suppuration  at  many  points,  will  be  found  a 
difficult  matter.       Each  case  must  be  judged  on  its  own  merits. 
It  must  not  be  forgotten  that  there  is  a  limit  to  the  amount  of 
force  which  may  be  exerted  in  the  separation  of  adhesions  sur- 
rounding a  kidney  :  surgical  manipulation   ought  never  to  be 
carried   into   brute   force.      Very  dense    adhesions    should    be 
divided  by  scissors  ;  forceps,  where  necessary,  being  placed  on 
the  bleeding  points.     In  cases  where  nephrotomy  has  been  per- 
formed, it  is  usually  found  that  enucleation  from  the  capsule  is 
more  feasible  than   enucleation  from  the  circumrenal  fat.     In 
cases  of  old-standing  suppuration,  with  great  enlargement,  the 
vena  cava  and  the  aorta  may  be  intimately  adherent  to  the  cap- 
sule.    One  such  case  was  recently  met  with  in  the  post-mortem 
room  of  the  Bristol  Infirmary ;  here  it  was  simply  impossible, 
after  death,  to  dissect  apart  the  vascular  walls  and  the  renal 
capsule.       In  another  case,  for  similar  reasons,  the  organ  could 
not  have  been  removed  by  any  proceeding  claiming  to  be  recog- 
nised as  surgical.     In  such  cases,  where  complete  removal  is 
out  of  the  question,  an  artificial  pedicle,  including  some  renal 
tissue,  may  be  formed  at  some  distance  from  the  middle  line. 
The  tissue  left  will  probably  either  atrophy  or  slough ;  and  the 
danger  of  wounding  vena  cava  or  aorta  will  have  been  avoided. 
The  kidne}^  having  been  freed,  the  next  step  is  to  secure  the 
pedicle.      This    is    a   proceeding    demanding   great    care    and 
delicacy.     A  few  surgeons  recommend  that  the  arter}'  and  the 
vein  should  be  ligatured  separatel}'.     In  many  cases  this  will  be 
found  impossible  ;  in  none  is  it  necessary.     Indeed,  the  walls  of 
the  vein  or  veins,  by  acting  as  a  sort  of  padding,  may  add  to 
the  safety  of  ligation,  preventing  the  thread  from  slipping  and 
distributing  the  pressure  on  the  artery  or  arteries.     As  a  matter 
of  fact,  the  only  deaths  as  yet  recorded  from  secondary  haemor- 
rhage were  in  two  cases  where  the  vessels  were  separately  tied. 
The  vessels  are  ligatured  in  a  body  ;  the  ureter,  separately. 


566  NEPHRECTOMY. 

The  kidney  is  first  most  carefully  raised  out  of  its  bed,  and 
handed  to  an  assistant,  who  holds  it  steadily  in  both  hands, 
exerting  no  traction  on  the  pedicle.  The  fingers  of  the  left 
hand  (or  the  right  hand,  as  may  be  most  convenient),  surround- 
ing the  pedicle,  isolate  ureter  and  vessels  as  far  as  possible  by 
teasing  out  the  cellular  tissue  between  them.  Pulsation  in  the 
artery  is  a  guiding  sign  of  importance,  A  ligature  of  thick  silk 
is  carried,  by  an  aneurism  needle  in  the  other  hand,  around  the 
vessels,  and  tied.  While  the  ligature  is  being  tightened,  all 
traction  must  be  taken  off  the  pedicle.  The  ureter,  isolated  as 
far  as  possible,  is  caught  in  a  pair  of  compression  forceps,  and 
left  to  be  dealt  with  as  seems  best  afterwards.  The  kidney  is 
now  deliberately  cut  away,  at  a  safe  distance  from  the  site  of 
ligation,  by  successive  snips  of  the  scissors ;  and  while  this  is 
being  done,  all  tension  on  the  pedicle  must  be  relaxed.  An 
artery  may  be  dragged  through  a  very  tight  ligature  which 
encloses  other  tissues  ;  and  this  artery,  recoiling  afterwards, 
may  bleed.  If  it  is  impossible  to  bring  the  pedicle  fully  within 
sight,  then  a  large  catch-forceps  should  be  placed  upon  it  out- 
side the  ligature,  and  division  made  between  forceps  and  kidney. 
Or  a  temporary  ecraseur,  of  rope  or  wire,  may  be  used  for  the 
same  purpose.  Every  possible  precaution  should  be  taken 
against  the  occurrence  of  haemorrhage. 

The  ureter  is  separated  from  the  pelvis  by  a  stroke  of  the 
scissors.  If  it  is  much  thickened,  and  its  mucous  membrane 
ulcerated,  Thornton's  admirable  plan  of  fixing  the  divided 
extremity  in  the  parietal  wound  should  be  adopted.  If  it  is 
fairly  healthy,  it  may  be  ligatured  and  left  in  the  wound. 

In  some  cases  of  large  suppurating  kidney  it  may  be  impos- 
sible to  manufacture  a  pedicle  composed  of  vessels  only  at  a 
safe  distance  from  the  aorta  or  vena  cava.  In  this  case  the 
simplest  plan  is,  to  surround  the  base  of  the  organ  with  a  tem- 
porary ligature  attached  to  an  ecraseur,  and  cut  away  the 
diseased  tissues  close  to  it.  Tait's  temporary  rope-clamp  is 
very  suitable  for  this  purpose.  If  the  kidney  is  very  large,  it 
may,  while  this  compression  is  being  exerted,  be  cut  away  in 
portions,  to  the  great  simplification  of  the  operation.     The  diffi- 


THE  OPERATION.  567 

culty  of  delivering  an  enormous  kidney  through  a  lumbar  wound 
is  thereby  avoided,  and,  more  important  still,  the  risks  of  trac- 
tion on  the  vessels  are  escaped.  When  the  organ  is  shaved 
away  down  to  the  position  of  the  temporary  compression,  the 
pedicle  may  be  dealt  with  deliberately  by  ligation,  forci-pressure, 
or  cautery,  as  seems  best  at  the  time. 

There  would  seem  to  be  no  extra  danger  in  placing  the  liga- 
ture quite  close  to  the  aorta  or  vena  cava.  But  most  surgeons 
would  endeavour  to  give  these  vessels  as  wide  a  berth  as  possible 
— not  only  to  avoid  injury  to  their  walls,  but  also  to  escape  the 
risk  of  extension  into  their  lumina  of  the  thrombotic  plugs. 

A  final  examination  is  made  of  the  pedicle  and  of  the  cavity 
of  the  wound.  All  blood-clot  is  removed,  any  bleeding  points 
are  secured,  and  the  peritoneum  is  carefully  examined,  to  make 
certain  that  it  has  not  been  torn.  A  peritoneal  rent  is  at  once 
closed  by  a  continuous  catgut  suture  placed  from  the  outside, 
which  will  cause  accurate  apposition  of  its  serous  surfaces.  If 
the  colon  has  been  exposed  on  its  retro-peritoneal  aspect,  it  also 
must  be  examined  for  injury. 

A  large  rubber  drain  is  placed  in  the  bottom  of  the  cavity, 
and  the  wound  sutured  by  deep  and  superficial  stitches.  The 
peritoneum,  pushed  backwards  by  intra-abdominal  pressure, 
soon  closes  in  over  the  large  cavit)^  Primary  healing  is  the 
rule ;  and  the  progress,  as  soon  as  the  first  dangers  are  over,  is 
usually  very  rapid. 

Abdominal  Nephvectomy. — The  incision  may  be  made  either  in 
the  ordinary  way,  through  the  linea  alba  ;  or,  after  the  method 
introduced  by  Langenbuch,  through  the  linea  semilunaris  on 
the  side  of  the  kidney  to  be  removed.  Langenbuch's  method 
is  now  almost  universally  adopted. 

The  length  of  the  incision  must  be  sufficient  to  admit  the 
whole  hand — at  least  four  inches — even  if  the  kidney  is  of 
normal  size ;  if  the  kidney  is  enlarged,  the  length  of  the  incision 
must  be  made  to  correspond.  Its  middle  point  is  at  the  level 
ot  the  umbilicus.  When  the  abdominal  cavity  is  entered,  a 
large  flat  sponge  is  inserted,  to  keep  the  intestines  out  of  the 


■^68  NEPHRECTOMY. 

way  and  to  absorb  effused  blood.  Before  proceeding  to  remove 
the  kidney,  the  state  of  the  other  will  have  been  ascertained  as 
accurately  as  possible  by  examination  with  the  hand  passed 
through  the  parietal  opening. 

The  kidney  is  exposed  by  tearing  through  the  peritoneum 
where  it  forms  the  outer  layer  of  the  meso-colon.  The  inner 
layer — that  between  the  colon  and  the  middle  hne — contains  the 
vessels  which  supply  the  bowel,  and  incision  through  it  may 
cause,  and  in  fact  has  caused,  gangrene  of  the  gut.  Two  or 
three  fingers,  passed  through  this  opening,  enlarge  it  by  tearing 
and  stretching,  and  separate  the  front  of  kidney  from  the  cir- 
cumrenal  fat.  When  a  way  has  been  opened  to  the  renal  vessels, 
these  may  be  exposed,  or  at  least  brought  nearer  to  the  field  of 
vision,  by  hooking  up  the  peritoneal  flaps  with  a  retractor, 
which,  in  the  hands  of  an  assistant,  at  the  same  time  makes  the 
parietal  wound  gape.  The  vessels  are  carefully  isolated  with 
the  forefinger.  A  ligature  is  passed  round  them  with  a  blunt 
aneurism  needle  and  tied.  The  ureter  is  caught  in  forceps, 
which  are  left  attached.  The  organ  is  now  completely  separated 
from  its  surroundings,  the  vessels  are  divided  at  a  safe  distance 
from  the  ligature,  the  ureter  is  cut  through,  and  the  whole  mass 
lifted  out  of  the  wound.  If  there  is  any  doubt  as  to  the  security 
of  the  ligature,  a  long  catch-forceps  should  be  placed  on  the  end 
of  the  pedicle,  while  a  second  ligature  is  applied  behind  the  first. 
In  most  cases  double  ligatures  have  been  used. 

The  ureter  is  treated  as  in  lumbar  nephrectomy.  If  it  is 
fairly  healthy,  it  is  ligatured,  cleansed,  and  returned  ;  if  it  is 
diseased,  lined  with  thick  granulations,  and  contains  putrid  pus 
its  divided  extremity  may  be  fixed  in  the  wound,  as  suggested 
and  practised  by  Thornton  ;  or  turned  out  through  an  opening 
in  the  loin,  as  suggested  by  Morris.  In  such  cases  as  strumous 
pyelitis,  where  the  disease  often  extends  down  the  ureter,  this 
extra-peritoneal  treatment  of  the  ureter  lessens  the  chances  of 
its  becoming  a  new  abscess-sac,  and  permits  of  its  being  irrigated 
and  disinfected.  Thornton's  plan  has  been  criticised,  as  inviting 
the  subsequent  occurrence  of  intestinal  obstruction  by  raising 
up  a  tense  band  between  bladder  and  loin. 


CHOICE  OF  OPERATION.  569 

The  cavity  is  finally  cleansed,  and  examined  for  bleeding 
points.  The  peritoneal  rent  falls  together  naturally,  and  requires 
no  suture.  If  pus  or  urine  has  escaped  during  the  manipulations, 
a  drainage  tube  should  be  placed  in  the  bottom  of  the  wound ; 
otherwise,  drainage  is  unnecessary.  The  parietal  wound  is 
closed  in  the  ordinary  way. 

Choice  of  Operation. — Whether  the  lumbar  or  the  abdominal 
method  be  selected  in  a  given  case,  will  depend  on  many  cir- 
cumstances. Firstly,  there  is  the  predilection  of  the  operator. 
That  men  of  such  experience  and  success  as  Tait  and  Thornton 
should  prefer  the  abdominal  method,  is  a  very  strong  argument 
in  its  favour.  But  the  force  of  the  argument  is  weakened,  in  so 
far  as  it  refers  to  surgeons  in  general,  from  the  fact  that  those 
men  who  prefer  the  abdominal  operation  are  also  men  of  very 
large  experience  in  performing  abdominal  sections  for  other 
purposes.  To  most  surgeons  the  lumbar  operation  would  com- 
mend itself,  as  being  more  easy  of  performance. 

Then  there  is  the  question  of  safety.  The  general  mortality 
after  the  lumbar  operation  is  considerably  less  than  that  after 
the  abdominal.  Out  of  233  cases  collected  by  Gross,"'  iii  by 
the  lumbar  method  gave  a  per-centage  mortality  of  36.93,  while 
120  by  ventral  incision  gave  50.83  per  cent,  mortality.  Newman 
gives  the  mortality  after  lumbar  nephrectomy  as  30.5  per  cent., 
and  after  abdominal  as  47.1  per  cent.  It  may,  however,  be 
reasonably  urged  against  any  conclusions  drawn  from  these 
statistics,  that  the  simplest  cases  were  naturally  selected  for  the 
lumbar  operation,  and  the  most  difficult  for  the  abdominal. 
There  are  no  figures  to  show  what  mortality  the  abdominal 
method  or  the  lumbar  would  have  given,  each  in  unselected 
cases.  It  is  just  possible  that  the  abdominal  method,  in  those 
cases  where  the  lumbar  was  adopted,  would  have  given  even 
better  results.  Indeed,  in  the  hands  of  a  few  operators,  with 
cases  that  were  certainly  far  from  being  simple,  the  results  in 
abdominal  nephrectomy  are  far  ahead  of  the  average  in  lumbar 

nephrectomy. 

*  Amer.  Journ.  Med.  Sc,  July,  1885. 


570  NEPHRECTOMY. 

We  cannot  ignore  these  facts,  and  compare  the  value  of 
general  lumbar  nephrectomies  with  general  abdominal  nephrec- 
tomies by  figures  alone.  All  that  can  be  said  is,  that,  so  far, 
the  general  superiority  of  the  one  to  the  other  has  not  yet  been 
proved  ;  and  the  surgeon  is  left  absolutely  to  his  own  discretion, 
in  each  case,  as  to  the  operation  he  shall  adopt. 

Looking  at  the  mechanical  details  of  the  operations  them- 
selves, we  find  that  certain  cases  are  most  suitable  to  one  method, 
and  some  to  the  other.  Generally  speaking,  it  is  possible  before 
operation  to  make  a  sound  selection ;  but  frequently  it  is  not. 

By  the  lumbar  method,  less  space  is  given  for  removal  of 
the  kidney ;  the  important  procedure  of  ligature  of  the  pedicle 
is  carried  out  at  some  distance  from  the  surface,  and  frequently 
out  of  sight ;  and  there  is  not  the  same  facility  in  dealing  with 
bleeding  points  in  the  tissues  from  which  the  kidney  has  been 
enucleated.  On  the  other  hand,  the  lumbar  method  is  an  extra- 
peritoneal operation  ;  it  gives  more  facility  for  the  separation  of 
strong  adhesions  behind  the  kidney;  and  in  the  case  of  its  being 
unwise,  as  in  abscess,  or  in  tumour  infecting  the  surrounding 
tissues,  to  proceed  to  removal,  it  is  less  serious  to  the  patient. 
In  the  case  of  abscess,  it  has  the  further  advantage  of  permitting 
of  treatment  by  incision  and  drainage,  without  serious  risks  of 
peritonitis. 

Langenbuch's  operation  is,  in  its  way,  a  perfect  surgical 
procedure,  securing  its  aims  by  a  minimum  of  injury  to  sur- 
rounding tissues.  In  the  linea  semilunaris,  the  advantages  of 
avoiding  large  muscular  masses  are  secured ;  and  by  tearing 
through  the  peritoneum  in  front  of  the  colon,  the  vitality  of  the 
bowel  is  not  endangered.  It  gives  plenty  of  room  for  removal 
of  the  kidney.  Lastly,  it  secures  the  all-important  advantage  of 
giving  information  as  to  the  condition  of  the  alternate  kidney. 
Its  disadvantages,  in  addition  to  the  opening  of  the  peritoneal 
cavity,  are  chiefly  the  difficulty  of  separating  adhesions  behind 
a  large  kidney,  and  the  dangers  from  rupture  of  abscess-cysts 
inside  the  cavity. 

Bearing  in  mind  the  advantages  and  disadvantages  peculiar 
to  each  operation,  we  can  roughly  specify  the  cases  most  suit- 
able for  each. 


CHOICE  OF  OPERATION.  571  " 

By  the  lumbar  method,  all  small  kidneys  may  be  removed. 
These  include  ordinary  examples  of  ureteral  fistula,  and  cases 
of  wounds  of  the  kidney  in  which  there  is  urinary  extravasation 
or  suppurative  disintegration  of  tissue.  It  ought  to  be  selected 
for  all  small  growths  of  the  kidney,  and  particularly  if  it  is 
movable.  It  is  best  employed  for  all  enlargements  containing 
fluid — hydatid,  hydro-nephrotic,  or  purulent — in  which  incision, 
with  drainage,  has  not  produced  cure.  In  cases  of  calculus  in 
which  the  renal  tissue  is  completely  disorganised,  the  lumbar 
method  is  the  best. 

The  ventral  incision  is  most  suited  to  large  non-adherent 
solid  tumours,  and  to  those  movable  kidneys  which  have 
become  diseased  and  are  unsuitable  for  nephrorraphy.  In 
very  fat  subjects,  the  ventral  incision  may  be  easier  than  the 
lumbar,  as  permitting  of  easier  approach.  In  very  lean  sub- 
jects, both  operations  are  much  facilitated — the  lumbar  more, 
perhaps,  than  the  ventral. 

A  word  must  be  said  on  the  plan  recommended  by  Thornton, 
but  now  abandoned  by  him,  which  IMorris  has  called  "Lateral 
Retro-peritoneal  Nephrectomy."  In  this  plan,  the  incision  is 
made  further  outwards  than  the  linea  semilunaris — so  far  out, 
in  fact,  as  to  permit  exposure  of  the  kidney  by  the  peritoneum 
being  pushed  aside  without  opening  it,  as  in  ligature  of  the 
external  iliac.  The  advantages  of  making  the  incision  in  the 
linea  semilunaris  are  perhaps  more  ideal  than  real :  an  ab- 
dominal section  is  about  as  easily  performed  by  division  of 
muscles  as  of  fasciae  ;  the  bleeding  is  easily  controlled,  and  the 
wounds  unite  just  as  readily.  If  there  is  any  advantage  in 
going  further  outwards,  the  division  of  muscle  need  not  deter 
us.  In  cases  of  considerable  enlargement  of  the  kidney,  for 
which  only  this  method  would  be  selected,  the  peritoneum  is 
pushed  inwards,  and  reflexion  of  it,  without  entering  the 
abdomen,  is  easy  enough.  It  is  doubtful,  however,  if  by  this 
lateral  incision  it  is  as  easy  to  deal  with  the  pedicle  as  in 
Langenbuch's  operation. 


Section  IX. 


OPERATIONS    ON    THE    LIVER    AND 
GALL-BLADDER. 


SURGICAL    ANATOMY    OF    THE    LIVER. 

The  surgery  of  the  liver  being  concerned  with  diseases  which 
cause  enlargement  of  the  organ,  it  behoves  us  to  know  accu- 
rately the  limits  of  the  space  it  normally  occupies.  The  limits 
of  percussion  dulness,  relative  and  absolute,  are  well  enough 
known  ;  but,  as  the  organ  is  overlapped  by  lung  above,  and 
as,  at  parts  where  it  is  thin,  it  lies  in  close  contact  with  air- 
containing  viscera  below,  these  limits  may  not  be  anatomically 
correct. 

On  the  right  side,  a  transverse  line  passing  through  the 
junction  of  the  fifth  rib  with  its  cartilage  would  graze  the  top 
of  the  right  lobe  at  its  highest  point.  In  fact,  the  highest  level 
of  the  liver  almost  touches  the  lower  border  of  the  fourth  rib. 
On  the  left  side,  a  transverse  line  running  through  the  junction 


SURGICAL   ANATOMY.  573 

of  the  sixth  rib  with  its  cartilage  would  pass  close  to  the  upper 
and  outer  limits  of  the  left  lobe.  Below,  its  margin  is  just 
covered  by  the  ribs  behind  :  as  it  comes  to  the  front,  it  leaves 
the  cartilage  of  the  tenth  rib  on  the  right  and  crosses  obliquely 
to  the  left,  towards  the  junction  of  the  fifth  left  rib  with  its 
cartilage. 

A  triangular  area  of  liver  surface  is  thus  left  uncovered  by 
anything  but  abdominal  wall ;  and  it  is  in  this  area,  usually 
increased  in  dimensions,  that  many  surgical  procedures  have  to 
be  carried  out.  The  sharp  free  margin,  with  its  notch  a  little 
to  the  right  of  the  middle  line,  indicating  the  attachment  of  the 
broad  ligament,  may  frequentl}'  be  palpated.  From  the  notch 
to  the  umbilicus  runs  the  double  fold  of  peritoneum  known  as 
the  longitudinal  or  suspensory  ligament.  Its  parietal  attach- 
ment is  along  the  inner  border  of  the  right  rectus  muscle  ;  its 
free  border  contains  the  fibrous  cord  known  as  the  round  liga- 
ment, which  is  the  remains  of  the  obliterated  umbilical  vein. 
At  the  notch  the  round  ligament  passes  behind  the  liver  along 
the  longitudinal  fissure.  It  must  not  be  forgotten  that  the 
umbilical  vein  is  not  always  completely  obliterated,  and  that  a 
wound  of  it  may  cause  haemorrhage.  This  fact  must  be  noted 
in  the  making  of  long  incisions  in  the  region. 

The  extent  to  which  the  right  lung  and  pleura  overlap  the 
liver  varies  considerably  in  health.  When  the  liver  is  enlarged 
it  rises  upwards,  encroaching  on  the  pulmonary  space ;  but 
though  the  level  of  the  upper  surface  is  raised  both  actually  and 
to  percussion,  and  though  the  lung  may  be  pushed  up  in  front 
of  it,  the  diaphragmatic  pleura  still  retains  its  position.  A 
puncture  above  the  normal  level  of  the  lower  limits  of  the 
pleura,  or  the  insertion  of  the  diaphragm,  though  it  may  not 
pass  through  lung,  will  traverse  the  pleura,  and,  if  there  are  no 
adhesions,  will  enter  the  pleural  cavity.  The  level  of  the  pleura 
in  the  right  axillary  line  is  at  the  lower  border  of  the  ninth  rib  ; 
and  if  variations  occur  on  this  side  as  frequently  as  they  do  on 
the  left  side,  we  must  not  be  surprised  to  find  it  placed  lower. 

The  liver  possesses  some  range  of  movement.  Following 
the  movements  of  the  diaphragm,  it  descends  with  inspiration 


574  OPERATIONS  ON   THE  LIVER. 

and  ascends  with  expiration.  If  there  is  occasion  to  stitch  a 
wound  in  the  hver  to  the  parietes,  the  evil  effects  of  this  con- 
tinual movement  may  be  minimised  by  fixing  the  sutures  at  a 
distance  as  great  as  possible  from  the  rib  margins.  Unim- 
portant displacements  take  place  as  the  position  of  the  indi- 
vidual varies,  and  as  the  abdomen  is  compressed  or  relaxed.  A 
real  pathological  displacement  is  seen  in  the  rare  condition 
known  as  wandering  or  floating  liver.  Though  most  of  the 
cases  so  described  have  proved  to  be  errors  in  diagnosis,  a  few, 
perhaps  a  dozen,  are  attested  by  post  mortem  examination  or 
incontrovertible  physical  signs.*'  In  the  great  majority  of  cases 
the  condition  has  been  found  associated  with  pendulous  ab- 
domen. In  none  is  treatment  called  for  beyond  the  wearing  of 
an  abdominal  belt. 

The  structure  of  the  liver  is  such  that  we  should  expect  it  to 
be  intolerant  of  surgical  interference.  But  experience  would 
seem  to  point  the  other  way.  Its  capsule  is  ver}'  closely  adhe- 
rent, and  so  thin  as  to  be  incapable  of  bearing  much  strain  from 
sutures.  The  tissue  is  very  friable  and  very  vascular  ;  but  the 
blood-stream  is  very  sluggish,  and  easily  controlled  by  pressure 
such  as  may  be  exerted  by  sponges  or  a  row  of  sutures. 

The  gall-bladder  (Fig.  74),  lying  on  the  under  surface  of  the 
liver  in  a  shallow  groove  between  the  lobulus  quadratus  and  the 
right  lobe,  is,  when  healthy,  beyond  the  reach  of  palpation.  Its 
fundus  extends  a  little  lower  than  the  edge  of  the  liver,  and  lies 
in  a  shallow  depression,  whose  margin  can  sometimes  be  felt 
below  the  inner  border  of  the  ninth  costal  cartilege.  In  this 
position  it  is  a  little  to  the  right  of  the  outer  margin  of  the 
right  rectus  muscle,  and  can  be  reached  by  an  incision  through 
the  upper  end  of  the  right  linea  semilunaris. 

The  bladder  itself  is  about  four  inches  in  length,  and  about 
an  inch  broad,  with  a  normal  capacity  of  a  little  over  an  ounce. 
It  is  fixed  to  the  under  surface  of  the  liver  simply  by  the  peri- 
toneum,   which   passes   over   it.      Occasionally   the   peritoneal 

*  Consult  Thierfielder,  Ziemssen's  Cycl.,  vol.  iv.,  p.  48.  Landau,  Dcr 
Wandcrleber  und  der  Hdngerbauch  dev  Fraiien.  Berlin,  1885.  Larionoff,  Rubin- 
ovitch,  Dmitrieff,  and  Botkin  ;  Abstract  in  Loud.  Med.  Rec,  Aug.  15th,  18S5, 
by  Dr.  Idelson,  who  gives  further  references. 


SURGICAL  ANATOMY. 


575 


folds  meet  on  its  upper  surface  between  it  and  the  liver,  forming 
a  sort  of  mesentery.  On  one  occasion  when  performing  chole- 
cystotomy  on  the  cadaver,  I  found  a  double  fold  of  peritoneum 
passing  between  the  free  surface  of  the  bladder  and  the  interior 
margin  of  the  foramen  of  Winslow.  As  another,  though  less 
perfect,  example  of  this  anomaly  was  found  in  the  post-mortem 
room  within  a  few  months,  I  suspect  that  this  condition  is  not 


Fig.  74.      (Weisse.) 
The  under  surface  of  the  Liver ;  the  Duodenum  and  the  Pancreas. 

I.  Cystic  Arteries  supplying  Gall-bladder.  2.  Obliterated  Umbilical  Vein.  3.  Obliterated 
Branch  to  Vena  Portfe.  4.  Hepatic  Duct.  5.  Hepatic  Artery.  6.  Obliterated  Ductus 
Venosus.  7.  Inferior  Mesenteric  Vein  discharg;ing  into  the  Splenic  Vein.  8.  Ductus 
Communis  Choledochus.  g.  Probe  entering  the  l3uct  and  coming  out  at  the  Orifice  in  the 
Duodenum.  lo.  Cystic  Duct. — The  inferior  Vena  Cava  is  crossed  by  the  lines  from  8  and  9. 
The  superior  Mesenteric  Vein  crosses  the  transverse  portion  of  the  Duodenum  and  passes 
under  the  Pancreas  to  join  the  Splenic  \'ein  in  the  Vena  Portse. 


very  rare.  This  abnormality  need  not  interfere  seriously  with 
operative  proceedings  ;  but  if  met  with  unexpectedly,  it  might 
be  confusing. 

The  cystic  duct,  about  an  inch  long,  leaves  the  neck  of  the 
bladder  at  a  very  obtuse  angle,  passes  a  little  towards  the  left 


576  OPERATIONS   ON   THE  LIVER. 

in  the  gastro-hepatic  omentum,  accompanied  with  its  artery, 
and  joins  the  hepatic  duct  at  an  acute  angle.  These,  joining, 
form  the  ductus  communis  choledochus,  which,  after  a  course 
about  three  inches  long  in  the  right  border  of  the  lesser  omen- 
tum, passes  with  the  pancreatic  duct  obliquely  through  the 
inner  wall  of  the  descending  portion  of  duodenum.  The  cystic 
duct  can  readily  be  examined  through  a  ventral  incision ;  and  a 
dilated  or  obstructed  common  duct  can  be  felt,  at  least  through 
the  first  part  of  its  course.  In  any  manipulation  that  may  be 
carried  out  on  these  ducts,  their  close  relations  with  the  portal 
vein  and  the  hepatic  artery  must  be  borne  in  mind. 

The  fibrous  coat  of  the  gall-bladder,  though  thin,  is  very 
strong  and  tough,  and  is  not  easily  dilated.  The  thin  layer  of 
muscular  fibres  is  arranged  mainly  in  longitudinal  direction. 
The  mucous  coat  is  everywhere  elevated  in  ridges,  which  are  so 
arranged  as  to  produce  polygonal  depressions,  most  highly 
developed  near  the  middle  of  the  cavity.  At  the  neck,  one 
large  ruga  overhangs  the  entrance  to  the  cystic  duct,  and  acts 
as  a  sort  of  valve.  When  the  bladder  is  over-distended,  these 
rugae  are  usually  obliterated.  In  the  cystic  duct  the  mucous 
membrane  is  raised  into  half  a  dozen  or  a  dozen  oblique  folds, 
arranged  so  as  to  form  a  sort  of  interrupted  spiral.  These  folds 
increase  the  difficulty  of  gall-stones  being  passed  onwards.  Any 
distension  of  the  duct  causes  the  intervalvular  spaces  to  be 
distended,  producing  a  sort  of  cork-screw  appearance. 

The  relations  of  the  bowels  to  the  gall-bladder  are  unim- 
portant, except  in  view  of  the  operative  formation  of  a  fistula 
between  the  two.     This  will  be  discussed  farther  on. 


Operations  upon  the  Liver. 

Surgical  operations  are  performed  on  the  liver  for  abscess 
and  for  hydatids.  The  operations  are  various  :  all  of  them  are 
of  the  nature  of  proceedings  for  the  evacuation  of  cystic  collec- 
tions of  fluid.  Although  most  of  the  proceedings  involve  wound- 
ing of  liver  tissue,  the  special  name  "Hepatotomy"  is  given 
only  to  that  operation  wherein  an  abdominal  section  is  made, 
and  the  liver  tissue  is  directly  incised  through  the  parietal 
wound.  The  name  is,  of  course,  equally  applicable  to  incision 
through  the  costal  parietes.  Partial  "  Hepatectomy"  must 
now  be  included  amongst  operations  on  the  liver,  since  Lan- 
genbuch-'  removed  (unsuccessfull}-)  a  pedunculated  mass  of 
hepatic  tissue  which  caused  great  pain  and  pressed  on  the 
pylorus  and  neighbouring  structures. 

The  various  operations  will  be  most  conveniently  considered 
under  the  heads  of  the  diseases. 


HEPATIC    ABSCESS. 

Anatomical  Characters. — The  fact  that  chiefly  concerns  the 
surgeon  is,  that  the  abscess  is  sometimes  multiple.  In  the 
majority  of  cases,  however,  especially  if  of  some  duration,  the 
abscess  is  single.  There  is  always  a  tendency  for  abscesses,  if 
multiple,  to  coalesce  ;  so  that  if  one  abscess  is  opened,  and 
pressure  be  removed  from  the  walls  of  its  neighbour,  there  is  a 
likelihood  of  the  second  bursting  into  the  cavity  of  the  first.  In 
most  the  abscess  is  covered  with  healthy  tissue,  with  uninflamed 
capsule,  and  an  incision  may  have  to  be  carried  some  distance 
through  the  healthy  substance  to  reach  it.  If  it  is  permitted  to 
burst  naturally,  it  is  most  frequently  fatal.  Rarely  it  bursts 
through  the  skin.  Sometimes  it  bursts  into  the  peritoneal 
*  Bcrl.  klin.  Woch..  iS8S,  iii. 
38  ' 


578  OPERATIONS   ON   THE   LIVER. 

cavity  or  pericardium,  when  it  causes  death.  It  may  open  into 
the  pleura,  when  it  is  usually  fatal.  The  most  favourable 
openings  are,  into  the  bowel  and  into  the  lung ;  though  in 
both  cases  the  prognosis  is  grave.  In  any  case  where  free 
evacuation  not  into  a  dangerous  site  has  taken  place,  there  is 
a  remarkable  tendency  for  the  abscess  cavity  to  close  up  and 
cicatrise,  while  the  liver  readily  regains  the  power  of  discharging 
its  normal  functions. 

Diagnosis. — The  diagnosis  of  abscess  of  the  liver  is  sometimes 
very  difficult,  or  even  impracticable  ;  nevertheless,  in  most  cases, 
especially  with  the  help  of  the  exploring  needle,  something  like 
certainty  may  be  arrived  at.  To  begin  with,  we  may  have  a 
history  of  residence  in  hot  climates,  and  perhaps  of  malaria  or 
dysentery.  There  may  be  a  history  of  rigors.  Sometimes  also 
it  would  appear  to  be  connected  with  operations  on  the  rectum. 
There  is  the  characteristic  muddy  complexion  ;  the  harassed, 
anxious,  restless  expression  ;  the  rapid  pulse  and  the  elevated 
temperature.  The  tongue  is  coated  with  white  fur  ;  and  there 
will  be  an  irritable  stomach,  with  vomiting.  Locally  there  is 
pain  and  tenderness  in  the  hepatic  region,  with  enlargement, 
sometimes  very  considerable,  of  the  organ  itself.  Occasionally, 
but  not  frequently,  there  is  fluctuation.  The  presence  of  jaun- 
dice is  rather  against  than  in  favour  of  abscess.  When  the 
abscess  bursts  into  the  lung,  the  chocolate-coloured  expectora- 
tion is  pathognomonic  ;  before  it  bursts,  this  sign  may  be  got 
from  exploratory  puncture. 

It  is  most  liable  to  be  confounded  with  empyema  at  the  base 
of  the  right  pleura,  and  it  has  been  mistaken  for  pleurisy  and 
pneumonia.  I  have  seen  a  large  abscess  of  the  liver  diagnosed 
as  abscess  of  the  kidney  ;  and  the  reverse  is  just  possible.  The 
nodular  feel  of  a  cancerous  liver  will  usually  distinguish  it  from 
a  suppurating  one ;  and  if  no  nodules  exist  on  the  surface,  and 
the  new  growth  be  behind,  we  can  fall  back  upon  the  pyrexia  that 
accompanies  the  latter.  In  hydatids  also  there  is  no  pyrexia, 
very  little  constitutional  disturbance,  and  but  little,  if  any,  pain: 
the  hydatid  fremitus  is  so  rarely  felt  as  to  be  of  little  value 
clinically. 


HEPATIC  ABSCESS.  579 


SURGICAL    TREATMENT. 

For  liver-abscess,  as  for  other  abscesses,  there  may  be  said 
to  be  no  treatment  that  is  not  surgical.  True,  as  in  other  cases, 
the  abscess  may  become  absorbed  naturally ;  but  that  is  a  result 
so  rare,  that  no  prudent  man  would  wait  for  it.  And  we  must 
not  delay  the  necessary  opening  too  long.  If  we  wait  for  the 
abscess  to  point  at  a  convenient  spot,  we  may  have  waited  too 
long,  and  the  abscess  may  elect  to  point  at  an  inconvenient 
spot.  On  similar  grounds,  we  must  not  wait  for  the  doubtful 
formation  of  adhesions  to  the  body  walls.  They  may  never  form 
there ;  and  if  they  did,  it  is  doubtful  if  we  could  diagnose  them. 
There  is  nothing  for  it  but  removal  of  the  pent-up  pus,  as  soon 
as  an  abscess  is  diagnosed. 

The  surgical  measures  available  are  : 

(i)  Aspiration. 

(2)  Puncture  by  trocar — leaving  the  cannula  in  situ. 

(3)  Opening  by  caustic  or  by  thermo-cautery. 

(4)  Direct  incision  into  the  abscess  through  the  body  walls. 

(5)  Incision  a  deux  temps,   after  the   artificial  formation  of 

adhesions  between  the  liver  and  abdominal  walls. 

(6)  Incision,  and  drainage   by  abdominal  section — Hepa- 

totomy. 

(i)  The  employment  of  the  aspirator  in  hepatic  abscess  must 
be  regarded  rather  in  the  light  of  a  tentative  and  exploratory 
measure,  than  as  a  permanent  cure.  It  is  now  used  more 
extensively,  perhaps,  than  published  literature  would  lead  us  to 
expect.  For  clearing  up  a  diagnosis,  and  giving  temporary 
relief,  the  removal  of  quantities  of  pus  from  the  liver  by  aspi- 
ration is  of  undoubted  value,  and  not  attended  with  much  danger. 
Ransohoff 's  case  of  hepatotomy  was  aspirated  without  benefit, 
and  he  had  to  incise  afterwards.*  It  may  tell  us  where  the  col- 
lection mainly  lies,  and  may  even  afford  some  light  as  to  whether 
the  abscess  is  single  or  multiple,  but  it  can  scarcely  be  expected 

•  N.  Y.  Med.  Rec,  No.  22,  1882,  p.  258. 
38   * 


580  ■  OPERATIONS   ON   THE  LIVER. 

at  one  operation  to  be  curative.  In  a  good  few  cases  aspiration, 
repeated  more  than  once,  has  been  followed  by  cure.  Ball, 
Maclean,  Hammond,  and  others  have  had  fairl}^  good  results 
from  aspiration.'^' 

In  the  use  of  the  aspirator,  its  thorough  cleansing  with  anti- 
septic lotions  must  be  seen  to.  The  needle  may  be  introduced 
full  of  I-20  carbolic  lotion;  the  skin  at  the  site  of  puncture 
must  be  thoroughly  purified,  as  some  of  the  epidermic  scales  may 
be  carried  into  the  abscess  cavity  on  the  point  of  the  needle, 
and,  if  impure,  be  a  cause  of  septic  infection.  The  movements 
of  the  needle,  following  the  movements  of  the  liver  (if  it  moves 
with  respiration),  must  not  be  checked,  as  thereby  the  liver  tissue 
may  be  torn  and  permit  escape  of  pus  into  the  peritoneum. 

(2)  Puncture  by  Trocar — leaving  the  cannula  to  permit  drain- 
age— is  a  procedure  by  no  means  new.  In  1842  Murray! 
advocated  it  ;  and  since  then  it  has  been  in  quite  general  use, 
and  is  esteemed  by  many  as  the  most  favourable  of  all  plans. 
An  ordinary  medium  size  instrument  is  used;  though  De  CastroJ 
used  a  hollow  trocar,  with  perforations  corresponding  to  similar 
ones  on  the  cannula.  The  trocar  is  left  in  situ  for  two  or  three 
da3'S,  w^ien  adhesions  will  have  formed,  and  is  then  replaced  by 
a  drainage  tube  of  some  sort.  The  purifying  of  the  trocar  is  to 
be  carried  out  as  carefully  in  this  proceeding  as  in  aspiration. 
Some  antiseptic  material,  such  as  terebene  with  vaseline,  or 
eucalyptus  or  salicylic  cream,  may  be  smeared  over  the  trocar. 
The  full  details  of  Listerism  will  by  most  be  considered  as 
affording  an  additional  probability  in  favour  of  asepticism 
throughout  :  if  the  spray  is  not  used,  perhaps  sal  alembroth 
wool,  with  frequent  cleansing  of  the  neighbourhood  of  the 
wound,  would  be  as  good  a  dressing  as  any. 

An  indication  in  favour  of  the  employment  of  the  trocar 
would  be,  the  tendency  of  the  abscess  to  point,  shown  by 
oedema,   or  some  redness  and   tenderness  of  the   skin.     Some 

*  See  Editorial,  Annals  of  Surgery,  March,  1S87. 

t  London  Med.  Gazette,  No.  38,  p.  566. 

\  Desabscis  du  foie  des  pays  chauds  et  de  leur  triatement  Chir.,  Paris,  1870, 


HEPATIC  ABSCESS.  581 

danger  may  attend  its  use,  however.  In  such  a  case  as  one  of 
those  operated  upon  by  Knowsley  Thornton,  where  the  omen- 
tum, with  large  veins  coursing  through  it,  lay  adherent  on  the 
surface  of  the  liver,  serious  bleeding  might  arise.  The  risk  of 
setting  up  inflammation  of  the  liver  substance  by  puncture  with 
fine  instruments  is  very  small.  Indeed,  Trousseau  used  punc- 
ture by  several  needles,  as  a  safe  means  of  setting  up  inflamma- 
tory adhesion  between  the  serous  surfaces  of  the  liver  and  the 
abdominal  wall,  as  a  preliminary  to  incision.  But  it  must  not 
be  forgotten  that  puncture  with  trocar,  after  all,  taps  the  ab- 
dominal cavity  ;  and,  being  done  in  the  dark,  may  cause  serious 
injury  to  an  abdominal  organ  other  than  the  liver  ;  and  may 
even  permit  of  the  escape  of  pus  into  the  abdominal  cavit3\ 

(3)  Gradual  opening  by  caustic,  and  b}^  thermo-cautery  applied 
to  the  abdominal  wall  over  the  tumour,  are  proceedings  whereby 
a  liver  abscess  ma}^  be  opened.  Both  are  slow  and  painful  pro- 
ceedings, and  are  not  likely  to  be  brought  into  competition  with 
other  more  rapid  and  less  painful,  while  equally  efficient,  methods. 
Recamier-"  advocated  the  use  of  caustic  potash  applied  to  the 
abdominal  wall  for  liver  abscess.  This  process  of  gradual 
perforation  by  destructive  chemical  or  thermic  agents  is  more 
in  vogue  for  the  treatment  of  h3-datids  of  the  liver  than  for 
abscess. 

(4)  Direct  Incision  into  the  abscess  through  the  abdominal  or 
thoracic  walls  would  be  carried  out  only  if  there  were  signs  of 
the  abscess  bursting  of  its  own  accord.  Redness,  tenderness, 
and  some  swelling  at  any  part  over  a  hepatic  tumour  which  is 
probably  suppurating,  may  be  taken  as  an  indication  that  the 
matter  is  forcing  its  way  to  the  surface.  In  such  cases  there 
will  be  adhesions  between  the  liver  and  the  overlying  peritoneum, 
and  an  opening  may  be  made  with  safety. 

It    need  scarcely  be  said  that  such  a  tendency  to  point  is 
neither  to  be  waited  for  nor  encouraged.     The  chances  of  an 
abscess  of  the  liver  escaping  towards  the  abdominal  or  thoracic 
*  Velpeau,  Mdd.  Optrat.,  2nd  Ed.,  iv.,  p.  19. 


582  OPERATIONS   ON   THE   LIVER. 

parietes  are,  considering  the  amount  of  surface,  at  least  not 
greater  than  the  chances  of  its  escaping  through  the  diaphragm 
or  into  the  peritoneum.  And  before  signs  of  pointing  appear 
the  patient  will  have  been  reduced  to  a  very  low  ebb. 

After  such  incision,  conducted  antiseptically,  a  large  drainage 
tube  will  be  inserted.  If  the  discharge  continues  sweet,  there 
will  be  no  need  for  syringing  or  irrigation  of  the  cavity ;  if  it  is, 
or  becomes,  putrid,  then  frequent  washings  with  some  trust- 
worthy antiseptic  solution  must  be  instituted. 

(5)  Incision  in  two  stages — after  the  manner  of  Graves,*  who 
made  the  incision  only  as  far  as  the  peritoneum  ;  or  of  Begin 
(1830),!  who  went  through  the  peritoneum — has  much  to  recom- 
mend it.  The  operation  in  two  stages  is  that  favoured  by  Volk- 
mann,  and  at  the  present  day  is  known  by  his  name.  It  is,  in 
fact,  an  old  application  of  the  modern  principle  of  creating 
adhesions  between  a  hollow  abdominal  viscus  which  is  to  be 
opened  and  the  parietes,  when  there  is  risk  from  escape  of  the 
contents  of  that  viscus  and  not  very  great  urgency  for  making 
the  opening.  In  the  case  of  hepatic  abscess  there  is  urgency, 
and  consequently  this  double  operation  Avill  not  often  commend 
itself. 

In  Graves's  procedure,  some  lint  or  other  material  is  pushed 
to  the  bottom  of  the  wound  in  the  parietes,  setting  up  simple 
inflammation  of  the  parietal  peritoneum,  which  thus  in  a  few 
days  becomes  adherent  to  the  liver.  Some  uncertainty  attaches 
to  the  plan  of  Begin,  as  it  has  been  found  that  the  liver  does  not 
always  come  up  to,  and  lie  in  contact  with,  the  wound  in  the 
parietes;  and  thus  adhesions  do  not  certainly  form.  There  is 
always  the  risk  in  the  operation  which  does  not  lay  open  the 
peritoneum,  that  omentum  or  even  bowel  may  lie  directly  under 
the  opening  and  be  wounded  when  the  liver  is  incised.  These 
objections  are  partly  met  by  suturing  the  liver  surface  to  tbe 
parietes,  as  recommended  by  Barwell.:J: 

*  Dublin  Hasp.  Rep.,  May,  1S27.         t  Journ.  Hebdom.,  1830,  i.,  p.  417. 
I  Lancet,  Jan.  29th,  18S7. 


HEPATIC    ABSCESS.  583 

(6)  Hepatotomy — the  name  usually  given  to  direct  incision 
through  the  Hver  tissue,  after  abdominal  section — is  the  operation 
which  most  commends  itself  for  hepatic  abscess.  With  lapar- 
otoni}',  the  risks  of  wounding  omentum  or  bowel  are  done  away 
with  :  we  see,  and  can  control,  the  bleeding  from  the  liver ;  the 
danger  of  escape  of  the  abscess  contents  into  the  peritoneum 
can  be  met  and  overcome,  and  if  they  do  so  escape  they  can  be 
mopped  up  ;  while,  lastly  and  not  least  important,  a  second 
abscess  can  be  seen  and  opened,  as  has  already  been  done  in  at 
least  one  case.     (Thornton.) 

To  Tait  of  Birmingham  belongs  the  chief  merit  of  introducing 
and  establishing  the  operation  of  hepatotomy.  He  had  done  the 
operation  ten  times  when  his  work  was  published — nine  times 
for  hydatids,  and  once  for  abscess.  All  were  successful.  Thorn- 
ton has  published  two  cases, — one  of  suppurating  hydatid  cyst, 
done  as  a  forlorn  hope  when  the  patient  was  profoundly  septi- 
caemic  after  five  tappings,  Avhich  failed  ;  the  other  of  hydatids, 
which  was  successful.  It  frequently  happens  that,  after  various 
surgical  manceuvres,  hydatid  disease  of  the  liver  suppurates,  and 
then  may  be  considered  and  treated  as  an  abscess.  Bryant 
has  in  at  least  twelve  such  cases  operated  by  direct  incision,  in 
each  instance  successfully ;  and  other  surgeons  have  had  similar 
experiences.  When  such  cysts  suppurate,  plentiful  adhesions  to 
the  parietes  will  probably  be  found  ;  and  if,  after  careful  dis- 
section down  to  the  cyst-wall,  there  are  found  adhesions  to  the 
parietes,  the  operation  is  simplified  to  a  mere  incision,  for  ad- 
hesions do  away  whith  the  necessity  for  sutures.  But  in  every 
case,  unless  we  are  certain  to  the  contrary,  we  ought  to  act  as  if 
there  were  no  adhesions. 

Ransohoff*'  has  operated  successfully  for  abscess,  making  all 
the  divisions  by  thermo-cautery. 

In  Australia,  where  hydatid  disease  is  more  common  than  in 
England,  there  is  a  growing  tendency  to  the  treatment  of  all 
cases  of  abdominal  hydatids  by  direct  incision  after  laparotomy. 

The  site  for  incision  will  be  made  over  the  most  prominent 
part  of  the  tumour,  and,  if  there  is  no  reason  to  the  contrary, 
*  N.  Y.  Med.  Rcc,  No.  22,  1S82,  p.  258. 


584  OPERATIONS  ON   THE   LIVER. 

will  be  longitudinal.  A  fairl}'  long  incision,  from  four  (Tait)  to 
five  (Thornton)  inches,  will  be  necessar}^,  to  permit  of  the  neces- 
sar}-  intra-peritoneal  manipulations.  Should  examination,  after 
abdominal  section,  show  that  the  liver  is  adherent  to  the  panetes 
at  an}-  point,  the  opening  should  be  made  through  the  area  of 
adhesion,  even  if  this  do  not  correspond  with  the  opening  in  the 
parietes.  Such  an  opening  may  be  made  with  trocar;  it  is 
made  permanent  by  the  insertion  of  a  drainage  tube.  Should 
there  be  no  adhesions,  the  opening  is  made  directly  into  the 
liver.  The  liver  tissue  being  recognised  by  its  characteristic 
appearance,  several  soft  flat  sponges  are  placed  round  the  spot 
selected  for  making  the  opening,  to  absorb  any  fluid  that  may 
escape.  Then,  if  we  think  it  necessary  for  more  accurate 
diagnosis,  or  to  relax  the  walls  of  the  abscess  cavity  and  permit 
of  its  being  raised  up  more  readil)^  after  incision,  we  may  insert 
the  largest  needle  of  an  aspirator,  and  withdraw  some  of  the 
contents.  A  knife  is  then  passed  in  along  the  side  of  the  needle, 
and  the  forefinger  is  made  to  follow  the  knife.  While  an  assistant 
helps  in  maintaining,  by  pressure,  exact  coaptation  of  the  parietes 
to  the  liver  structure,  the  forefinger  helps  this  by  hooking  up  the 
abscess-wall.  When  all  is  ready,  the  knife  is  carried  in  along  the 
forefinger,  and  the  incision  freely  enlarged.  Then  the  lips  of  the 
wound  are  quickly  seized  by  two  or  more  catch-forceps,  and  kept 
everted  against  the  parietal  wound  by  means  of  these.  Bleeding 
may  be  arrested  by  a  squeeze  with  pressure  forceps,  or,  if  this 
fail,  b}'  a  continuous  suture  of  not  too  fine  catgut  or  silk. 
Probably  the  abscess  will  nearly  empt}^  itself  readily  enough  ;  if 
it  does  not,  a  large  rubber  tube  lying  in  carbolic  lotion  may  be 
pinched  at  the  end,  and,  when  placed  in  the  bottom  of  the 
cavity,  will  act  as  a  siphon  and  suck  out  all  the  fluid.  I  have 
used  with  advantage  such  means  for  the  removal  of  ascites  and 
fluid  from  an  ovarian  cyst  that  was  laid  open,  and  have  no  doubt 
it  would  ansv/er  here. 

When  the  abscess  is  empty,  the  finger,  carried  round  its 
walls,  will  examine  for  signs  of  a  second  abscess,  which  will  be 
opened  by  pushing  the  finger  into  it,  or  by  Lister's  sinus  forceps 
or  by  trocar,  as  seems  best.     The  whole  of  the  purulent  material 


HEPATIC   ABSCESS.  585 

being  removed,  the  cyst-walls  are  to  be  gently  cleaned  out  with 
a  soft  sponge  held  by  long  forceps.  Rough  manipulation  here 
might  easily  cause  bleeding,  either  by  breaking  down  the  no- 
toriously tender  granulations  of  a  hepatic  abscess,  or,  if  there  is 
a  membranous  wall,  by  tearing  it  off  the  liver.  While  this  is 
going  on,  an  assistant  has  been  gently,  steadily,  and  firmly 
keeping  the  liver  in  contact  with  the  parietes.  A  sponge  is  now 
placed  in  the  liver  opening,  and  the  sponges  inserted  at  the 
beginning  are  removed,  and  the  peritoneum  is  cleansed  of  any 
escaped  or  peritonic  fluid.  If  the  pus  is  foetid,  an  antiseptic  will 
be  applied  to  the  walls  of  the  emptied  sac.  Thornton  uses  iodine 
for  this  purpose. 

When  the  sac  has  been  emptied  of  its  pus,  and  the  peritoneal 
cavit}'  is  free  of  all  fluids,  the  whole  length  of  the  incision  in 
the  liver  is  stitched  to  the  margins  of  the  wound  in  the  parietes, 
and  a  large  glass  or  rubber  or  celluloid  drainage-tube  is  in- 
serted. If  there  is  much  discharge,  it  must  be  removed  once  or 
twice  daily  by  S3'ringing,  so  that  it  may  be  kept  innocuous  in 
case  of  absorption.  Later  on,  as  the  cavity  shrinks  and  its  walls 
thicken,  syringing  may  be  emplo3'ed  less  frequently,  or  even 
dropped.  An  abundance  of  absorbent  antiseptic  dressing  will 
be  necessar}'. 

Thornton*  has  successfully  treated  a  case  of  hepatic  abscess 
by  incision  and  drainage  through  the  pleura.  The  patient  had, 
fifteen  months  previously,  been  cured  b}-  aspiration  of  an  abscess  of 
the  left  lobe;  an  abscess  having  appeared  after  two  months  in  the 
right  lobe,  which  was  not  relieved  by  aspiration, Thornton  decided 
to  drain  along  the  course  of  the  aspirating  needle.  He  cut  out 
a  lozenge-shaped  piece  of  skin,  carefully  peeled  the  parietal 
and  visceral  pleurae  along  small  incisions,  and  sutured  them  to 
each  other  b}''  a  continuous  suture,  and  so  completely  shut  off  the 
pleural  cavity  from  the  line  of  drainage.  A  track  for  the  drainage- 
tube  was  made  by  incision  along  the  side  of  the  trocar.  Healing 
took  place  without  trouble.  Hunsner  and  Schede  have  operated 
in  the  same  situation  after  resection  of  the  ribs. 
*  Brit.  Med.  Journ.,   1886,  ii.,  p.  901. 


586  OPERATIONS  ON   THE  LIVER. 

HYDATIDS    OF    THE    LIVER. 

Anatomical  Characters. — The  liver  echinococcus  is  usually 
single.  When  near  the  surface,  it  may  stand  out  as  a  rounded 
fluctuating  tumour,  distending  the  abdomen  in  the  hepatic  region ; 
when  at  a  distance  from  the  surface,  it  causes  a  more  diffuse 
enlargement.  The  liver  tissue  is  thinned  out  and  expanded  over 
it.  Where  there  is  no  suppuration,  there  is  little  or  no  pain,  and 
constitutional  disturbance  is  slight  or  absent.  It  is  exceedingly 
slow  in  growth,  sometimes  existing  for  ten  or  even  twenty  years 
without  causing  troublesome  symptoms.  Very  frequently  the 
echinococcus  dies  and  shrivels  up,  leaving  a  curdy  or  chalky 
mass  behind,  enclosed  in  a  cyst- wall.  If  it  grows,  there  are 
almost  no  limits  to  the  size  it  may  attain.  When  the  cyst  grows 
at  some  distance  from  the  surface,  the  liver  tissue  is  spread 
evenly  over  it,  and  the  symptoms  may  be  nothing  more  than 
those  of  enlarged  liver.  Occurring  near  any  of  its  surfaces,  the 
cyst  may  cause  symptoms  by  pressure  on  any  of  the  neighbouring 
organs,  or  even  by  bursting  into  them.  On  the  upper  surface  of 
the  liver,  it  presses  upwards  the  diaphragm,  encroaching  on  the 
lung  and  causing  dyspnoea,  sometimes  almost  filling  the  right 
chest.  Extending  downwards,  it  may  cause  obstruction  to  the 
flow  of  bile,  and  jaundice,  by  pressing  on  the  biliary  ducts.  By 
compressing  the  vena  cava  or  portal  vein,  it  may  also  induce 
symptoms  of  venous  obstruction.  Rupture  in  any  direction  is 
always  immediately  dangerous,  and  may  be  ultimately  fatal  by 
causing  infection  with  the  parasites.  Rupture  into  the  vena 
cava  is  always  fatal;  into  the  peritoneum,  usually  immediately 
so,  and  still  more  frequently  ultimately  so.  Suppuration  is  rare, 
except  from  surgical  interference  of  some  sort. 

The  more  rare  multilocular  echinococcus  is  frequently  asso- 
ciated with  jaundice,  and  has  a  curious  connection  with  tumour 
of  the  spleen. 

Diagnosis. — In  a  comparatively  young  person,  a  slow-growing 
fluctuating  enlargement  of  the  liver  that  is  unattended  with 
pain,  fever,  or  cachexia,  is  probably  hydatid.  Perhaps  the 
conditions  most  closely  simulating  hydatids  are,  curiously 
enough,    chronic    hydro -nephrosis    and    ovarian    cyst.      Other 


HYDATIDS  OF  THE   LIVER.  587 

diseases  of  the  liver,  such  as  cancer  or  abscess,  are  less  likely 
to  be  mistaken  for  hydatids  than  the  diseases  mentioned.  Such 
an  experienced  observer  as  Thornton  operated  on  a  case  of 
h3'datids  of  the  liver,  thinking  it  was  ovarian  disease ;  and  it 
was  not  till  he  had  gone  some  way  through  the  operation  that 
he  knew  for  certain  what  he  was  dealing  with.  A  hydatid  cyst 
may  fluctuate  free]}-,  may  occup}^  nearly  the  whole  abdomen, 
and  give  resonance  in  the  flanks,  just  like  an  ovarian  cyst ;  the 
absence  of  any  palpable  connection  with  the  uterus  might  be 
explained  by  the  existence  of  a  long  pedicle,  while  the  con- 
tinuity of  its  dulness  with  that  of  the  liver  may  be  explained  by 
adhesions  to  the  latter.  From  hydro-nephrosis  of  the  right  side, 
the  diagnosis  may  be  still  more  difficult.  Many  cases  of  hydro- 
nephrosis have  been  operated  upon  in  the  belief  that  they  were 
ovarian  cysts ;  and  if  echinococcus  were  more  common  than 
it  is,  perhaps  hydro-nephrosis  would  just  as  frequently  be  con- 
founded with  hydatids  of  the  liver.  When  the  C3'st  exists  on 
the  upper  surface  of  the  liver,  its  diagnosis  from  pleurisy  is 
exceedingly  difficult.  As  Traube  has  pointed  out,  pain  in  the 
right  scapula,  as  pointing  to  liver  disease,  may  be  the  only 
symptom  to  guide  us.  In  such  cases,  of  course,  the  existence  of 
fever  and  other  well-known  accompaniments  of  pleuritic  effusion 
will  be  carefully  looked  for.  An  exploratory  puncture  will 
almost,  but  not  quite,  certainly  settle  the  diagnosis.  Echino- 
coccus fluid  is  non- albuminous,  contains  a  large  amount  of 
chloride  of  sodium,  and  is  usually  below  1.015  specific  gravity. 
No  other  fluid  of  the  body  has  these  characters.  The  presence 
of  booklets  in  the  fluid  withdrawn,  or  of  pieces  of  the  laminated 
echinococcus  membrane,  is  pathognomonic.  When  a  hydatid 
cyst  becomes  inflamed,  albumen  may  be  found  in  the  fluid,  and 
then  our  difficulties  are  increased.  When  there  is  clear  evidence 
of  suppuration,  we  must  operate  without  delay,  and  be  content 
to  make  the  diagnosis  after  the  fluid  has  been  withdrawn. 

SURGICAL   TREATMENT. 

Though  the  call  to  treat  a  stationary  or  very  slow-growing 
hydatid  cyst  may  not  be  urgent,  it  must  not  be  forgotten  that  a 


588  OPERATIONS   ON   THE  LIVER. 

patient  with  a  living  echinococcus  in  the  Hver  is  in  constant  and 
increasing  danger.  The  risks  of  suppuration  or  of  bursting  of 
the  cyst,  with  the  greater  likelihood  of  death  after  operation  on 
large  tumours,  make  early  treatment  advisable. 

The  treatment  of  hj^datids  is  entirely  surgical,  and  resolves 
itself  into  destruction  of  the  life  of  the  parasite  in  situ,  or  evacu- 
ation of  the  contents  of  the  cyst. 

For  causing  the  death  of  the  parasite  v^^e  have  electrolysis ; 
simple  puncture  ;  puncture,  with  removal  of  a  small  quantity  of 
the  fluid;  and  puncture,  with  injection  of  some  chemical  solution. 

x\s  electrolysis'''  has  not  yet  shown  better  results  than  simple 
puncture,  it  is  probable  that  it  does  good  simply  from  the 
mechanical  insertion  of  the  needles.  Acupuncture,  again,  has 
not  been  so  successful  as  removal  of  a  few  ounces  of  the  fluid 
by  means  of  the  aspirator.  It  has  been  found  that  this  proceed- 
ing in  some  way  kills  the  parasite,  which  then  shrivels  up  and 
becomes  innocuous.  The  operation  is  primaril}'  a  comparatively 
harmless  one  ;  though  Bryant  met  with  a  death  from  puncture 
of  a  misplaced  portal  vein,  probabl}'  letting  the  hydatid  fluid  get 
into  the  general  circulation.  There  is,  again,  some  risk  of  the 
fluid  escaping  into  the  peritoneal  cavity  through  the  opening 
left  after  puncture,  and  not  a  feAv  have  suppurated  in  conse- 
quence. The  injection  of  some  chemical  fluid,  such  as  iodine 
solution,  has  had  fairly  good  results. 

Each  case  must  be  a  law  for  itself;  but  in  an  ordinary  case 
of  slow  growth,  the  first  treatment  would  probably  be,  to  remove 
a  few  ounces  of  the  fluid  by  aspiration,  and  carefully  watch  the 
course  of  events.  If  the  cyst  refills  and  goes  on  increasing,  and 
more  particularly  if  signs  of  suppuration  appear,  some  plan  of 
opening  and  emptying  the  cyst  must  be  adopted.  With  this 
view,  we  have  various  old  plans  of  operating  by  causing  adhe- 
sions between  the  liver  and  parietes,  and  the  more  modern,  and 
more  perfect,  one  of  direct  hepatotomy  by  abdominal  section. 

For  producing  adhesions  Simon  f  recommended  and  prac- 

*  For  the  mode  of  applying  electrolysis,  see  Fagge  and  Denham's  paper, 
Med.  Chir.  Trans.,  vol.  xliv. 

t  Die  Echinocoecencysten  der  Nieren  und  des  perirenahn  Biirdcgeivches.  Stutt- 
gart, 1S77. 


HYDATIDS  OF  THE  LIVER.  589 

tised  multiple  puncture  of  the  tumour  through  the  parietes, 
and  evacuation  of  the  cyst-contents  by  incision,  when  adhesions 
would  have  formed  after  a  few  days.  The  first  puncture  is 
made  diagnostic  by  being  made  with  a  hollow  needle,  and 
removing  some  of  the  contents  for  examination.  Many  suc- 
cessful cases,  treated  after  this  method,  are  recorded,  and  some 
failures.  Volkmann  has  called  attention  to  the  danger  of 
echinococci  escaping  from  the  puncture  and  infecting  the  peri- 
toneum, and  Hiiter  relates  such  a  case  where  death  resulted. 

The  plan  of  causing  perforation  by  the  application  of  Vienna 
paste,  or  caustic  potash,  or  actual  cautery,  has  found  many 
adherents.  At  the  Congress  of  the  Societ}^  of  German  Surgeons 
in  1877,  Bardeleben  spoke  of  having  treated  no  fewer  than  forty 
such  cases  by  perforation  with  caustic,  and  with  uniform  suc- 
cess. He  applied  Vienna  paste  over  an  area  of  two  fingers' 
breadth,  which,  in  from  six  to  nine  days,  perforated  the  abdo- 
minal wall,  causing  adhesions  as  it  advanced,  and  then  the  C3'st 
was  opened  with  ease.  Subsequent  closure  of  the  opening 
always  took  place  without  trouble. 

For  causing  adhesion  to  the  parietes,  Ranke  recommends  an 
incision  through  the  peritoneum,  and  removal  of  two  semilunar 
pieces  of  that  membrane  at  the  sides  of  the  opening,  to  make 
the  wound,  gape.  After  a  week  or  so,  when  the  adhesions  are 
strong,  the  incision  is  made  without  an  anaesthetic  through 
the  insensitive  liver  tissue,  and  the  cyst  evacuated.  He 
speaks  of  four  cases  successfully  treated  in  this  manner,  in 
his  own  and  in  Volkmann's  clinic ;  and  other  successful  cases 
are  recorded. 

As  a  provision  against  the  escape  of  the  parasite  into  the 
peritoneal  cavity,  there  can  be  no  doubt  of  the  validity  of  the 
plan  of  perforation  by  caustic.  But  it  is  too  slow  and  too  pain- 
ful to  have  commended  itself  to  the  favour  of  English  surgeons. 
Multiple  puncture  has  been  justly  criticised  as  being  possibly 
uncertain  in  its  results ;  sometimes  causing  multiple  fine  adhe- 
sions, useless  for  the  end  in  view,  or  even  no  adhesions  at  all. 
To  both  proceedings  the  objection  may  be  raised,  that  it  is  more 
or  less  a  working  in  the  dark,  and  that  valuable  information 


590  OPERATIONS   ON   THE   LIVER. 

which  an  abdominal  section  might  afford  is  withheld.  The  only- 
objection  that  can  be  taken  to  the  procedure  of  leaving  the 
incised  peritoneum  to  adhere  over  the  liver  is,  that  the  delay 
has  not  the  same  strong  reasons  for  it  as  other  similar  proceed- 
ings have,  and  that  it  may  cause  a  loss  of  valuable  time  and 
possibly  be  a  cause  of  inflammation  in  the  cj^st. 

Hepatotoniy,  or  incision  and  evacuation  of  the  cyst  as  an 
immediate  sequel  to  laparotomy,  is,  comparatively  speaking,  a 
new  operation  for  hydatids  of  the  liver.  Lawson  Tait,  in  1883, 
was  the  first  who  wittingly  performed  the  operation  for  hydatids. 
Up  to  September,  1882,  he  had  operated  on  nine  cases,  in  all 
with  successful  result;  and  a  good  many  other  successful  cases 
have,  from  time  to  time,  been  recorded.  In  skilful  hands 
that  can  be  trusted  to  successfully  guard  against  escape  of 
the  fluid  into  the  peritoneum,  to  quickly  deal  with  possible 
haemorrhage,  and  to  accurately  suture  the  liver  wound  to  the 
parietal  opening,  the  operation  need  not  be  attended  with  much 
risk. 

The  steps  of  the  operation  are  essentially  the  same  as  in 
hepatotomy  for  abscess.  There  is  frequently  considerable  ten- 
sion inside  a  hydatid  cyst,  and  its  contents  may  be  ejected  with 
force  when  liberated.  The  whole  of  the  contents  must  be  gently 
removed  (Tait  has  used  a  gravy-spoon  for  this  purpose),  the 
cyst-walls  united  by  continuous  or  other  suture  to  the  parietes, 
and  a  large  drainage-tube  inserted.  In  one  case  Thornton,  with 
full  confidence  in  the  antiseptic  method,  used  no  drainage,'^'  and 
had  no  cause  to  regret  so  doing.  With  most,  however,  the  fear 
of  haemorrhage,  or  suppuration,  or  leakage  through  the  liver 
wound,  would  weigh  strongly  as  reasons  for  the  insertion  of  a 
drainage-tube. 

When  the  cyst  has  been  thoroughly  cleaned  out,  the  fore- 
finger is  made  to  explore  the  walls,  to  see  that  there  is  no 
further  cyst  or  even,  as  in  a  case  of  Pauly's,  an  abscess.  Before 
closing  the  wound,  most  punctilious  care  must  be  taken  over 
the  toilet  of  the  peritoneum ;  and,  during  this  manipulation,  a 
*  Med.  Times  and  Gaz.,  Jan.,  1SS3,  p.  89. 


HYDATIDS   OF  THE   LIVER.  591 

sponge  will  be  placed  in  the  liver  opening.  Exactly  similar 
precautions  as  to  the  coaptation  of  liver  and  parietes  will  be 
observed  as  in  hepatotomy  for  abscess. 

The  mortality  of  direct  hepatotomy  is  not  high.  Pilcher  '■^'-  has 
published  tables  of  64  operations — twelve  being  done  in  two 
stages,  and  53  (the  incompatibility  of  the  figures  is  not  explained) 
by  the  method  at  one  operation.  There  were  8  deaths  altogether, 
of  which  only  4  could  be  attributed  to  the  operation — a  mortality 
of  about  7  per  cent.  After  Volkmann's  method  17  operations 
were  all  successful. 

*  Annals  of  Surgery,  March,  1887. 


Operations  on  the  Gall-bladder. 

Operations  on  the  gall-bladder  are  performed  for  conditions 
arising  from  the  presence  of  gall-stones  and  from  obstruction  in 
the  biliary  ducts.  By  far  the  most  important  operation  is  that 
known  as  Cholecystotomy  :  Cholecj/stectomy  is  performed  by  a 
few  surgeons  ;  and,  besides  minor  proceedings,  such  as  puncture 
with  aspiration,  extended  sometimes  into  sounding  for  stone,  we 
have  other  special  proceedings  specially  named  — such  as,  Chole- 
lithtority  :  Chole-lithotomy;  Chole-duodenostomy  ;  and  Chole- 
enterostomy. 

History. — In  1618,  according  to  Thudichum,  Johannes  Fa- 
bricius  is  said  to  have  removed  gall-stones  from  the  gall-bladder 
of  a  living  subject.  Fabricius  Hildanus^'  refers  to  this  operation, 
but  it  is  not  clear  that  the  operation  was  not  done  post-mortem  ; 
the  only  evidence  of  the  subject  being  alive  being  the  some- 
what dubious  expression  "  delineatio  horum  lapidum  ad  viviim 
facta." 

To  Petit  t  is  undoubtedly  due  the  merit  of  having  founded 
the  surgery  of  the  gall-bladder.  In  1733  he  mooted  his  project  : 
his  most  important  papers  appeared  ten  years  subsequently. 
Petit's  opinions  were  far  in  advance  of  his  time.  He  discusses 
with  great  acumen  the  diagnosis  of  tumours  of  the  gall-bladder, 
and  the  sequences  of  biliary  retention.  He  recommends,  besides 
the  simple  incision  of  an  enlargement  adhering  to  the  peritoneum, 
two  other  operations  :  "  Tune  se  sera  dans  le  cas  oii  la  retention 
de  la  bile  est  portue  a  I'extreme,  et  le  malade  en  danger  de  mort : 
celle-ci  est  la ponction ;  I'autre  operation  .  .  .  c'est  la  litJiotomie,  je 
vieux  dire  I'extraction  des  pierres  hors  de  la  vesicule  du  fiel." 
His  description  of  these  operations  of  puncture  and  lithotomy 
would  almost  pass  muster  in  the  literature  of  the  advanced 
surgery  of  to-day.  It  may  be  affirmed  that,  till  ten  years 
ago,   the    surgery  of  the  gall-bladder  did   not  advance  a  step 

*  Obscrv,  Chiy. 
t  Mem.  de  VAcad.  Roy.  de  Chir.,  tome  i.,  p.  163.       Paris,  1743. 


HISTORY.  593 

beyond  where  Petit  left  it ;  on  the  contrar}^  it  fell  almost  into 
oblivion. 

Among  English  surgeons,  with  the  exception  of  that  shrewd 
surgeon  Samuel  Sharp,  Petit's  work  was  ignored  or  condemned. 
On  the  Continent,  Morand  (1757),  Haller  (1760  circa),  Herlin, 
Blochs,  and  others,  by  observations  and  experiments,  sought 
to  advance  Petit's  labours.  Bromfield,  in  1773,  wrote  to  con- 
demn the  operation.  Morgagni,  Chopart,  Desault,  and  Walter, 
about  the  end  of  the  eighteenth  century,  did  valuable  work 
in  varying  the  methods,  but  scarcely  in  improving  the  results. 
Richter  appeared  in  1798  with  a  htho-triptor,  and  explained 
how  fragments  could  be  removed  by  washing  :  he  also  advised, 
in  certain  cases,  the  operation  a  deux  temps,  as  described  for 
hydatids  of  the  liver. 

In  the  nineteenth  century  little  advance  was  made.  Delpech, 
in  1816,  rather  decried  the  operation;  and  Good,  in  1825,  spoke 
of  it  as  being  of  doubtful  value.  In  1828  Sebastian  described 
an  operation  whereby  adhesion  was  secured  between  the  gall- 
bladder and  the  peritoneum  before  opening  the  tumour — a 
suggestion  modified  by  Graves  of  Dublin.  In  1847  Dufresne 
recommended  opening  by  caustic  ;  soon  after  Recamier  advised 
the  trocar;  and  several  other  modifications  were  suggested. 

Thudichum,  in  1859,  wrote  with  an  insight  which  recalls  the 
work  of  Petit.  He  recommended  abdominal  section,  suturing 
of  the  unopened  gall-bladder  to  the  abdominal  wound,  and 
opening  after  several  days. 

In  1866  Luton  introduced  exploratory  puncture,  doing  no 
harm  ;  and  in  his  presence,  Thomas,  at  the  Hotel-Dieu  in 
Rheims,  discovered  a  stone  by  this  means.  This  procedure  has 
been  resuscitated  in  modern  times. 

The  modern  operation  of  cholecystotomy  was  first  performed 
by  Dr.  Bobbs  of  Indianopolis  in  1867.*  He  incised  the  gall- 
bladder, removed  some  fifty  small  calculi,  and  closed  the  incision 
by  one  suture.  His  patient  recovered.  Marion  Sims  f  followed 
with    an   operation  which,    though    unsuccessful,    had    a    most 

*  Trans.  Indiana  State  Med.  Sec,  1S68,  p.  68. 

+  Brit.  Med.  Joum.,  1878,  i..  Sii. 

39 


594  CHOLECYSTOTOMY. 

important  influence  in  advancing  the  surgery  of  the  gall-bladder. 
Sims  originated  the  name  cholecystotomy  {xoXi) — bile,  a.i'st(? — 
bladder,  70/0} — incision).  At  the  present  time,  as  regards  tech- 
nique and  results,  Tait  holds  the  leading  place  with  a  series 
of  some  twenty  published  cases,  all  successful. 

In  1882  Langenbuch  introduced  the  operation  of  cholecyst- 
ectomy, or  removal  of  the  gall-bladder ;  and  Thiriar,  Courvoi- 
sier,  and  others  took  it  up  favourably,  but  with  no  striking 
success. 

CONDITIONS  FOR  WHICH  THE  OPERATION   MAY  BE  PERFORMED. 

The  conditions  which  may  give  rise  to  a  nesessity  for  opera- 
tion may  be  conveniently  classified  as  follows  :••■ 

1.  Cholelithiasis. 

2.  Dropsy  and  empyema  of  the  gall-bladder. 

3.  Obstruction  in  the  ductus  choledochus. 

4.  Wounds  and  perforations  of  the  gall-bladder. 

Cholelithiasis. — The  great  majority  of  operations  on  the  gall- 
bladder are  performed  for  conditions  arising  out  of  the  presence 
of  gall-stones.  Apart  from  the  weakening  influences  of  the 
recurrent  agonies  of  biliary  colic,  there  are  certain  real  dangers 
to  life  to  be  apprehended.  The  effects  of  simple  colic  itself  have 
been  fatal.  The  stones  may  set  up  inflammation,  suppuration, 
and  even  gangrene,  in  the  bladder-walls.  They  ma}^  become 
wedged  in  the  cystic  duct,  or  pass  into  the  hepatic  duct  (though 
in  this  situation  they  usually  have  come  direct  from  the  liver), 
or  cause  obstruction  in  the  common  duct.  The  effects  of  back- 
ward pressure  are  seen  in  cystic  distension,  and,  where  the 
hepatic  or  the  common  duct  is  blocked,  in  jaundice.  Stones 
which  have  escaped  into  the  bowel  sometimes  cause  obstruction. 
Occasionally  they  perforate  the  bladder  through  an  ulcerated 
area,  either  directly  into  the  abdominal  cavit}^  causing  fatal 
peritonitis,  or,  after  the  formation  of  adhesions,  into  any  of  the 

*  See  Roth,   "  Zur  Chirurgie  der  Gallenwege,"  Langenbeck's  Archiv. 
Bd.  xxxi.,  Heft.  i. 


INDICATIONS  FOR   OPERATION.  595 

hollow  viscera  or  through  the  abdominal  wall,  forming  biliary 
fistulas.  Parietal  fistulae  are,  fortunately,  the  most  common. 
Fistulfe  communicating  with  the  stomach  and  the  bowels  are 
next  in  frequency.  Sometimes  the  communication  is  extended 
between  different  portions  of  bowel,  as  the  colon  and  duodenum. 
The  urinary  bladder  has  been  perforated.  Arteries  may  be 
ulcerated  through — the  pyloric,  for  instance.  The  diaphragm 
has  been  perforated,  and  stones  have  been  found  in  the  air- 
passages.  It  is  stated  by  some  that  gall-stones  are  an  exciting 
cause  of  cancer  of  the  liver  :  it  is  certain  that  they  are  frequent 
concomitants. 

In  obstruction  of  the  cystic  duct,  the  changes  are  local.  If 
the  obstruction  is  in  the  common  duct,  the  changes  are  general 
as  well  as  local ;  there  is  dilatation  of  the  biliary  channels  of  the 
liver  itself  as  well  as  of  the  gall-bladder,  with  the  symptoms  of 
obstructive  jaundice.  Changes  take  place  in  the  accumulated 
bile,  which  are  identical  in  the  bile-channels  and  in  the  gall- 
bladder. The  bile  is  first  transformed  into  a  yellowish-brown 
watery  fluid,  which  becomes  mixed  with  a  mucoid  secretion  from 
the  duct-walls.  If  the  obstruction  has  existed  for  some  weeks  or 
months,  the  bile  is  replaced  by  a  perfectly  clear  fluid  containing 
flakes  of  mucus,  but  little  or  none  of  the  proper  constituents  of 
bile,'''"  which  is  all  the  more  remarkable  that  the  tissues  generally 
may  be  saturated  with  it.  In  obstruction  of  the  common  duct, 
general  cholasmia  now  supervenes.  In  obstruction  of  the  cystic 
duct,  matters  may  remain  stationary  after  the  bladder  is  dis- 
tended, or  they  may  become  more  urgent.  Increase  of  tension 
may  go  on  to  inflammation,  suppuration,  or  even  ulceration  and 
perforation. 

Without  obstruction,  the  presence  of  gall-stones  may  either 
set  up  no  symptoms  at  all,  or  may  cause  any  degree  of  inflam- 
mation from  simple  catarrh  up  to  suppuration  and  necrosis. 
Accompanying  the  catarrh  we  sometimes  find  a  low  cellulitis  of 
the  outer  coats,  leading  to  subsequent  thickening  and  contrac- 

*  It  has  been  said  that  this  fluid  sometimes  contains  a  ferment.  My  friend 
Mr.  G.  M.  Smith,  lecturer  on  Physiology  at  the  Bristol  Medical  School,  fully 
tested  a  quantity  of  fluid  removed  by  me  in  a  case  of  cholecystotomy,  and 
found  no  evidence  of  the  presence  of  a  ferment. 

39  * 


596  CHOLECYSTOTOMY. 

tion.  But  this  cellulitis  is  sometimes  of  an  acute  nature,  leading 
to  great  increase  of  size  from  thickening  of  the  bladder-walls. 
One  of  Musser  and  Keen's  cases,  in  which  operation  could  not 
be  completed,  was  probably  of  this  sort. 

Tait  informs  us  that  he  has  found  in  the  majority  of  cases 
either  a  very  few  large  stones  or  very  man)^  small  ones.  An 
examination  of  collections  of  gall-stones  in  museums,  shows 
that  biliary  concretions  in  the  gall-bladder  generally  show  this 
peculiarity. 

Dropsy  and  Empyema  of  the  Gall-bladder. — In  most  cases  these 
conditions  are  sequels  of  obstruction  in  the  bile-ducts.  The 
most  common  cause  of  obstruction  is  a  gall-stone  ;  but  collec- 
tions of  parasites,  such  as  liver-flukes,  hj'datids,  or  worms,  have 
been  found  to  cause  blocking.  Stricture  following  localized 
inflammation,  and  obstructive  catarrh,  are  also  reckoned  as 
causes.  Rarely  the  cause  is  external,  arising  from  pressure  by 
a  new  growth  springing  from  a  neighbouring  organ. 

There  is,  practicall}^,  no  limit  to  the  amount  of  distension 
which  a  dropsical  gall-bladder  will  bear.  The  bladder- walls  are 
nearly  always  thinned.  Emp3'ema  does  not  usually  attain  to 
great  dimensions  :  perforation  is  liable  to  occur  when  distension 
is  excessive.  In  empyema,  the  walls  are  greatly  thickened  in 
some  places ;  at  others,  they  ma}^  be  thinned  by  stretching  or 
ulceration.  The  changes  which  take  place  in  retained  bile, 
leading  to  dropsy,  have  already  been  described  :  the  passage  to 
suppuration  is  easily  understood. 

Obstruction  in  tlie  Coiinnoii  Duct. — This  may  be  caused  by 
foreign  bodies  in  the  duct,  such  as  gall-stones,  worms,  or 
hydatids  ;  by  stricture  in  any  part  of  its  course ;  or  by  com- 
pression from  the  outside  by  inflammatory  exudations  or  new 
growths  in  neighbouring  organs.  Among  tliese  last  must  be 
reckoned  tumours  of  the  pancreas,  duodenum,  stomach,  and 
kidney.  The  bladder  may  become  distended  to  considerable 
dimensions,  and  the  contents  may  undergo  the  changes  already 
described. 


INDICATIONS  FOR   OPERATION.  597 

Jaundice,  passing  into  profound  cholaemia,  is  to  be  expected, 
with  its  well-known  train  of  symptoms.  Few  cases  last  more 
than  six  months  before  symptoms  of  cholaemia  appear,  and 
death  usually  supervenes  within  the  year.  One  case  is  recorded 
by  Murchison  in  which  there  was  complete  obstruction  for  six 
years. 

Wounds  and  Pevfovations  of  tlie  Gall-bladder. — The  gall-bladder 
may  be  wounded  by  cutting  or  piercing  instruments  ;  or  it  may 
be  perforated  by  ulceration  started  by  a  foreign  body  in  its 
cavit}^ ;  or  it  may  burst  from  over-distension.  Bursting  of  an 
empyema  is  always  fatal  ;  escape  of  a  foreign  body  with  the 
bladder  contents,  though  usually  fatal  in  a  very  short  time,  has 
in  a  very  few  cases  not  been  fatal  for  some  Aveeks.  Localised 
peritonitis  is  set  up,  which  confines  the  extravasated  contents  in 
a  suppurating  cavity  for  a  time.  Simple  extravasation  of  bile 
has  usually  been  reckoned  as  certainly  fatal.  But  the  experi- 
ments of  Schtippel,  Bostrom,  and  others  Avould  seem  to  show 
that  large  quantities  of  bile  may  be  absorbed  by  the  peritoneum 
without  causing  much  trouble ;  and  certain  recorded  cases  of 
wound  of  the  gall-bladder  show  that  a  similar  result  may  take 
place  in  the  human  subject.  Paroisse  records  a  case  in  which 
a  ball  remained  for  two  years  in  the  gall-bladder.  Sabatier  had 
a  patient  who  lived  seven  years  after  wound  of  the  gall-badder 
by  a  sword-thrust :  at  the  post-mortem  examination,  much  fluid 
bile  was  found  in  the  abdomen.  But,  in  spite  of  these  and  other 
cases,  the  general  experience  is,  that  wounds  of  the  gall-bladder, 
with  extravasation  of  bile,  are  nearly  alwa3^s  fatal.  Sometimes, 
before  death  takes  place,  there  is  an  enormous  accumulation  of 
bile  in  the  abdomen.  Thiersch  successfully  removed  forty-severr 
pints  of  what  appeared  to  be  pure  bile  from  the  abdomen  of  a 
boy  whose  gall-bladder  had  been  ruptured  by  a  blow. 

Diagnosis. — Cholelithiasis,  in  its  simplest  form,  is  diagnosed  by 
recurrent  attacks  of  hepatic  colic,  with  or  without  enlargement  of 
the  gall-bladder,  and  not  necessarily  accompanied  with  jaundice. 
The  symptoms  of  hepatic  colic  are  well  known.     Paroxysmal 


598  CHOLECYSTOTOMY. 

attacks  of  pain  in  the  epigastric  and  right  hypochondriac  regions, 
radiating  towards  the  back  and  shoulders,  often  preceded  by  a 
rigor,  frequently  accompanied  by  vomiting,  and  always  attended 
by  profound  constitutional  disturbance,  suggest  the  passage  of 
gall-stones.  The  paroxysms,  increasing  in  severity,  may  pass 
off  suddenly  in  a  few  hours :  rarely  do  they  last  more  than  one 
or  two  days.  The  liver  is  usually  enlarged  during  the  attack : 
and  occasionally  it  is  possible  to  detect  a  distended  gall-bladder. 
If  jaundice  is  present,  we  may  infer  that  there  is  occlusion  of 
the  common  or  the  hepatic  duct. 

If  there  is  permanent  occlusion  of  any  of  the  ducts,  there 
follows  permanent  distension  of  the  gall-bladder.  The  physical 
characters  of  an  enlarged  gall-bladder  are  of  importance.  In 
all  cases  it  will  appear  to  have  its  origin  in  the  right  hypo- 
chondrium.  When  first  discovered,  such  a  tumour  is  usually 
about  the  size  of  the  closed  fist ;  but  all  dimensions  are  met 
with,  even  up  to  filling  the  abdominal  cavity.  Kocher  operated 
successfully  on  a  case  in  which  the  disease  was  supposed  to  be 
ovarian  cyst ;  and  Tait  has  had  a  similar  experience.  The  line 
of  enlargement  is  usually  in  a  diagonal  line  from  the  normal 
situation  of  the  gall-bladder  towards  the  umbilicus.  Mr.  J.  W. 
Taylor''-  has  specially  insisted  on  this  point  as  an  important  aid 
in  diagnosis.  A  dull  note  is  usually  given  out  over  the  whole 
tumour,  but  sometimes  a  resonant  area  is  found  at  its  junction 
with  the  liver.  The  shape  of  an  enlarged  gall-bladder  has  been 
described  as  cordate,  or  pyriform,  or  globular.  According  to 
the  amount  of  tension  and  the  thickness  of  its  walls,  the  tumour 
may  be  hard  and  unyielding,  or  soft  and  semi-fluctuating.  Its 
consistency  is,  however,  not  easily  ascertained,  on  account  of 
its  tendency  to  slip  backwards  from  the  grasp.  The  tumour,  if 
not  of  large  dimensions,  moves  upwards  and  downwards  with 
the  liver  during  forced  expiration  and  inspiration. 

The  conditions  most  likely  to  be  mistaken  for  enlarged  gall- 
bladder are,  tumours  and  cysts  of  the  right  kidney,  and  movable 
kidney.     Any  solid  growth  of  the  kidney  may  be  mistaken  for 
an  enlarged  gall-bladder  ;  but  mistakes  are  most  likely  to  arise 
*  Bn't.  Med.  Journ.,  Jan.  31st  and  April  nth,  18S5. 


INDICATIONS  FOR   OPERATION.  599 

in  cases  of  cystic  tumours,  and  especially  of  hydro-nephrosis 
In  these  cases  symptoms  of  functional  disturbance  of  secretion 
of  urine  are  to  be  diligently  sought  for.  From  floating  kidney, 
the  points  of  distinction  refer  specially  to  peculiarities  in  shape, 
consistence,  and  range  of  mobility,  as  proper  to  each.  An 
important  criterion  is,  the  presence  of  resonant  bowel  overlying 
a  movable  kidney.  Hydatid  or  other  cysts  of  the  peritoneum 
might  be  a  possible  source  of  confusion.  A  patient  recently 
died  in  the  Bristol  Infirmary  of  aneurism  of  the  pyloric  artery ; 
for  two  months  the  diagnosis  was  enlargement  of  the  gall- 
bladder. Acupuncture  and  aspiration  are  not  recommended  as 
aids  to  diagnosis. 

Of  jaundice  as  a  factor  in  diagnosis,  no  more  need  be  said 
than  that  its  presence  in  a  marked  and  persistent  form  indicates 
obstruction  in  the  common  or  the  hepatic  duct.  Though  we 
might  expect  that  obstruction  in  the  common  duct  would  be 
uniformly  attended  with  cystic  distension,  and  obstruction  in 
the  hepatic  duct  with  cystic  collapse,  the  clinical  facts  are  by 
no  means  uniform  in  either  direction.  The  detailed  accompani- 
ments of  obstructive  jaundice  cannot  properly  be  considered 
here.  The  presence  of  leucin  and  tyrosin  in  the  urine,  and 
diminished  secretion  of  urea,  may  aid  in  diagnosis. 

The  diagnosis  of  wounds  of  the  gall-bladder  must  be  purel}' 
inferential,  unless  there  is  an  escape  of  bile  through  a  parietal 
wound.  Abdominal  shock,  with  a  sensation  of  distress  in  the 
right  hypochondrium  and  a  history  of  traumatism  in  that  region, 
followed  by  abdominal  distension  and  perhaps  by  jaundice, 
suggest  rupture  of  liver  or  gall-bladder,  or  both.  The  injury  is 
a  rare  one.  Perforation  by  a  gall-stone,  or  rupture  of  an  em- 
pyema, are  diagnosed  only  through  the  help  of  previous  history. 

Indications  for  Operation. — In  ever}''  case  of  wound  or  perfora- 
tion of  the  gall-bladder,  operation  ought  at  once  to  be  performed. 
Operation  gives  the  only  chance  of  recovery. 

In  every  case  of  empyema  of  the  gall-bladder  operation  is 
indicated.  Aspiration  is  only  a  temporary  measure,  and  it  is 
by  no  means  free  from  danger. 


600  CHOLECYSTOTOMY. 

In  every  case  of  dropsy  of  the  gall-bladder  operation  is  indi- 
cated. Aspiration  may  do  no  harm,  and  it  may  detect  the  pre- 
sence of  stone.  But  it  is  useless  towards  the  removal  of  the 
stone,  and,  generally,  it  has  no  beneficial  effect  on  the  disease. 

In  cases  of  cholelithiasis,  the  indications  to  operate  must  be 
guided  by  the  effects  produced  by  the  disease.  The  dangerous 
sequences  of  gall-stones  are :  frequently  recurring  attacks  of 
hepatic  colic,  which  wear  out  the  patient's  strength ;  jaundice, 
proceeding  to  dangerous  cholaemia ;  and  suppuration  in  the 
gall-bladder.  The  indication  in  each  instance  is  strengthened 
by  the  presence  of  an  enlarged  gall-bladder. 

No  general  rule  can  be  laid  down  as  to  the  weight  of  the 
indication  arising  from  hepatic  colic.  After  months  or  years  of 
intense  but  intermittent  suffering,  many  patients  get  well,  and 
remain  so.  On  the  other  hand,  a  patient's  life  may  be  rendered 
miserable,  or  his  active  existence  as  a  bread-winner  may  be  cut 
short,  by  persistently  recurring  attacks  of  hepatic  colic,  A  time 
then  comes  when  patient  and  surgeon  both  agree  that  it  is 
proper  to  interfere.  In  all  such  cases  the  patient's  desire  must 
have  great  influence  with  the  surgeon. 

In  cases  of  persistent  obstructive  jaundice,  operation  is  at 
the  same  time  indicated  and  contra-indicated.  Cholaemia,  not 
only  as  weakening  and  depressing  the  patient,  but  also  as  pre- 
disposing to  bleeding,  is  an  unfavourable  element.  In  only  seven 
of  Musser  and  Keen's  series  of  35  cases  of  cholecystotomy  was 
jaundice  present,*  and  five  of  these  cases  died, — half  of  the 
whole  mortality.  That  the  jaundice  had  much  to  do  with  this 
excessive  death-rate,  there  can  be  no  dispute :  this  suggests 
early  operation,  before  the  patient's  condition  is  lowered  by 
cholaemia. 

Where  evidences  of  suppuration  appear  in  cholelithiasis, 
operation  is  to  be  urged.  Every  day  that  passes  brings  in- 
crease of  danger. 

In  cases  of  obstruction  of  the  common  or  the  hepatic  duct, 
cholecystotomy  may  simply  prevent  death  from  cholaemia  by 
permitting  escape  of  the  biliary  poison.  Patients  can  live  with- 
*  Amer.  Journ.  Med.  Sc,  October,  1SS4. 


SOUNDING   FOR   GALL-STONES.  601 

out  discharge  of  bile  into  the  intestines.  But  Tait  has  shown 
how  a  stone  in  the  common  duct  can  be  crushed :  so  that  even 
in  these  cases  cure  may  be  effected. 

In  cases  of  obstruction  of  the  cystic  duct,  operation  in  the 
majorit}^  of  cases  will  not  only  relieve  pain,  and  remove  danger 
of  suppuration  in  the  gall-bladder,  but  will  also,  in  all  proba- 
bility, bring  about  complete  cure. 

As  to  the  viortality,  cases  are  as  yet  too  few  for  the  establish- 
ment of  trustworthy  data.  The  mortalit}^  in  skilled  hands  is 
very  small.  Tait  has  published  fort3'-one  cases,  with  two  deaths. 
If  operation  is  performed  before  cholasmia  supervenes,  a  death- 
rate  of  not  more  than  six  per  cent,  may  be  predicted.  Of  the 
thirty-five  cases  quoted  in  Musser  and  Keen's  table,'^-'  ten  died. 
Depaget  has  collected  78  operations,  to  which  one  of  my 
own  might  be  added,  making  79.  Of  these,  six  were  done  by 
immediate  peritoneal  closure :  three  died  immediately  from 
peritonitis,  one  had  recurrence,  and  two  recovered.  In  73, 
including  my  own,  the  gall-bladder  was  sutured  to  the  ab- 
dominal wound :  of  these  11  died — five  from  haemorrhage  and 
collapse,  others  from  ordinary  causes  or  accidents.  Collapse 
with  haemorrhage  would  seem  to  be  the  most  usual  cause  of 
death  ;  and  this  cause  is  most  potent  in  cholaemic  individuals. 
Jaundice,  therefore,  in  all  cases  coming  up  for  operation,  must 
be  regarded  as  a  contra-indication ;  and  specially  so  if  the 
jaundice  be  of  long  standing.  Amongst  the  bad  results,  count- 
ing practically  as  failures,  must  be  reckoned  the  considerable 
number,  about  one-third,  in  which  biliary  fistulae  have  remained 
for  months  or  years. 

Sounding  for  Gall-stones  with  a  probe  passed  through  a  hollow 
cannula  inserted  into  the  gall-bladder  was  proposed  by  Petit  J  in 
1733;  t)ut  was  not  put  into  practice  till  1876,  when  Bartholow 
successfully  used  the  method.  In  1878  Brown  §  sounded  gall- 
stones in  this  way.     A  similar  purpose  may  be  served  by  using 

*  Amcr.  Journ.  Med.  Sc,  October,  1884. 

t  Lancet,  Jan.  12th,  1889,  and  Journ.  de  Med.,  Brux.,  1888,  No.  24. 

I  Maladies  Cliir.,  i.,  282.      §  Brit.  Med.  Journ.,  1878,  ii.,  916. 


602  CHOLECYSTOTOMY. 

the  fine  needle  of  an  aspirator  as  a  sound.  Whittaker  of  Cin- 
cinnati, in  conjunction  with  Ransohoff,  in  1882",  employed  this 
plan.  Harley  in  1884,!  in  ignorance  of  Whittaker's  priority, 
practised  sounding  for  gall-stones.  These  cases  were  successful 
in  detecting  the  stone. 

The  proceeding  is  not  free  from  risk.  In  Harley's  case, 
after  a  short  interval,  enteritis  and  peritonitis  set  in,  and  killed 
the  patient.  In  Keen's  first  case,  not  a  little  haemorrhage  and 
considerable  local  peritonitis  followed  the  use  of  a  hypodermic 
syringe.  Unless  there  are  very  urgent  reasons  for  doing  so, 
few  men  would  care  to  risk  a  patient's  life  for  the  sake  of  making^ 
a  diagnosis.  Urgency  is  great  only  when  a  patient's  life,  in 
imminent  danger,  can  be  saved  by  a  very  grave  operation,  and 
an  error  in  diagnosis  would  be  a  catastrophe.  And  if  we  bear  in 
mind  the  blind  groping  nature  of  the  proceeding,  and  the  close 
contiguity  of  important  organs  and  vessels,  we  must  admit  that 
the  risks  are  scarcely  less  than  those  following  extravasation  of 
bile  or  pus.  Musser  and  Keen,  though  justly  criticising  the 
somewhat  crude  proceedings  of  Harley,  and  quoting  the  disas- 
trous result  of  his  own  case  to  disprove  his  statement  that  the 
operation  is  both  "easy  and  safe,"  still  look  upon  exploratory 
puncture  with  favour,  on  account  of  the  valuable  informatioa 
which  it  may  supply. 

I  look  upon  the  proceeding  with  no  favour  whatever.  If 
the  gall-bladder  were  considerably  enlarged,  if  its  walls  were 
thick,  and  it  lay  in  contiguity  with  the  abdominal  wall,  puncture 
might  be  safe  ;  but  we  can  very  rarely  be  certain  that  these 
conditions  are  present.  The  positive  detection  of  a  stone  in 
the  bladder  is  a  clinical  fact  of  supreme  importance  ;  but  a 
failure  to  detect  stone  is,  as  more  than  one  case  has  shown,  no 
proof  that  it  is  not  there.  And  it  is  not  the  presence  of  stone 
that  justifies  operation.  A  stone  or  stones  in  the  gall-bladder 
may  be  perfectly  harmless  ;  we  have  no  right  to  meddle  with 
them  unless  they  produce  serious  discomfort  or  danger. 

I  am  strongly  of  opinion,  that  in  cases  where  it  is  clear  that 

*  New  York  Med.  Rec,  i.,  1SS2,  p.  56S,  and  ii.,  18S2,  p.  25S. 
t  Med.  Times  and  Gaz.,  May  17th,  18S4. 


SOUNDING   FOR   GALL-STONES.  605 

surgical  interference  of  some  sort  is  called  for,  the  operation 
should  in  the  first  place  be  abdominal  section;  then,  exploration 
with  the  finger;  and  then,  cholecystotom}^,  if  the  operation  is  to 
be  anything  more  than  exploratory.  Of  course,  where  a  sup- 
purating gall-bladder  is  adherent  to  the  abdominal  wall,  mere 
incision  is  all  that  is  called  for — provided  the  incision  will 
permit  of  the  withdrawal  of  stones. 


Cholecystotomy. 

Cholecystotomy  is  the  name  given  to  incision  made  into  the 
gall-bladder  after  division  of  the  parietes.  It  may  be  followed 
by  removal  of  gall-stones — cholelithotomy ;  or  by  crushing  of 
stones  that  are  impacted  and  cannot  be  removed — cholelithotrity. 
In  other  cases  it  is  simply  of  the  nature  of  an  evacuation  of 
cystic  or  purulent  fluids,  followed  usually  by  drainage. 

The  parietal  incision  is  best  made  vertically  over  the  most 
prominent  part  of  the  tumour,  if  there  is  one ;  and  over  the 
situation  of  the  fundus  of  the  gall-bladder,  if  there  is  not.  The 
best  landmark  is  the  tip  of  the  cartilage  of  the  tenth  rib :  the 
fundus  of  the  gall-bladder  lies  directly  beneath  it.  Musser  and 
Keen  recommend  that  the  incision  be  made  parallel  to  the  ribs ; 
and  various  other  lines  of  incision  have  been  recommended. 
But  the  vertical  one  over  the  fundus  is  probably  the  best. 
Tait,  whose  experience  is  largest  and  whose  success  is  greatest, 
always  uses  it. 

The  skin  and  the  muscles  are  divided  in  the  ordinary  way. 
The  peritoneum,  pinched  up  between  two  pairs  of  catch-forceps, 
is  opened  by  slowly  cutting  through  the  elevated  fold  stretched 
between  them.  Through  the  opening  the  right  forefinger  is 
inserted,  and  the  bladder  explored.  If  the  bladder  is  much 
distended,  and  more  particularly  if  it  "  fills  the  abdomen,"  such 
exploration  is  impossible  (as  it  is  unnecessary)  until  the  fluid 
has  been  drawn  off.  If  the  bladder  is  small,  the  presence  of 
stones  may  be  easily  detected  by  touch.  But  sometimes,  it 
would  seem,  we  may  meet  with  considerable  difficulty  in  finding 
the  bladder. 

The  opening  is  made  in  different  wa3's,  according  as  the 
bladder  is  collapsed,  moderately  full,  or  enormously  distended. 
If  the  tumour  is  very  large,  its  contents  may  be  at  once  evacu- 
ated by  an  ordinary  cyst-trocar.  During  the  evacuation,  the 
cyst  is  gradually  brought  to  the  surface — and,  if  possible,  a  little 
way  out  of  the  wound — by  forceps  attached  by  the  side  of  the 


THE   OPERATION. 


605 


trocar.  But  the  cyst-wall  should  not  be  roughly  dealt  with  by 
compression-forceps;  as  it  must  be  left  behind,  we  must  be 
careful  not  to  cause  sloughing.  If  small  catch -forceps  are 
applied  in  the  line  of  incision  above  and  below  the  trocar 
opening,  the  chance  of  danger  from  injury  is  minimised  by 
having  the  bruised  area  in  the  line  of  attachment  to  the 
parietes.  This  caution  is  all  the  more  necessar}-,  in  dealing 
with  greatly  distended  gall-bladders,  when, 
as  is  frequently  the  case,  their  walls  are  very 
thin.  In  every  case  flat  sponges  are  suitably 
placed  around  the  site  of  puncture,  to  absorb 
any  fluid  that  may  escape. 

If  the  cyst-wall  is  very  tense  from  over- 
distension either  by  bile  or  by  pus,  it  is  best 
alwa3's  to  remove  the  fluid  contents  by  the 
aspirator  before  making  the  large  opening. 
An  excellent  needle,  which  may  at  the  same 
time  be  converted  into  a  blunt  probe,  is  that 
invented  by  Hodder.  (Fig.  75.)  The  needle 
is  inserted  as  low  dowm  on  the  tumour  surface 
as  possible,  because  as  the  fluid  is  removed 
the  cyst-wall  contracts  and  draws  the  open- 
ing upwards.  Any  drops  of  fluid  that  exude 
by  the  side  of  the  needle  are  at  once  mopped 
up.  When  the  fluid  is  removed,  two  small 
catch-forceps  are  placed,  one  at  each  side 
of  the  puncture ;  the  cyst-wall  is  drawn 
forwards,  and  vertically  divided  by  scissors 
to  an  extent  sufficient  to  admit  the  fore- 
finger. Before  this  opening  is  made,  it  will 
be  wise  to  place  a  sponge  below  the  gall- 
bladder. 
If  the  bladder  is  collapsed  or  but  slightly  distended,  the 
opening  may  at  once  be  made.  The  fundus  Is  caught  in  a 
catch- forceps,  and  gently  drawn  to  the  surface.  Below  the 
bladder  is  placed  a  flat  sponge,  which  keeps  the  bowels  out  of 
the  way  and  absorbs   any  fluid  that  may  escape.     A  second 


Fig.  75. 

Hodder' s  Guarded 

Aspirating 
Needle.     Half  size. 


606 


CHOLECYSTOTOMY. 


forceps  is  attached  by  the  side  of  the  first,  and  the  raised  fold 
between  them  divided  by  scissors  to  an  extent  sufficient  to 
admit  the  finger.  Any  bleeding  points  are  at  once  secured. 
The  forceps  placed  on  the  edges  of  the  wound  are  handed  to  an 
assistant,  whose  duty  it  is  with  gentleness  to  keep  the  opening 
in  the  bladder  steadily  forward  in  the  abdominal  opening ;  while 
he  is  also  careful  to  mop  up  any  fluid  that  may  well  up  while 
the  operator  has  his  fingers  or  instruments  inside  the  bladder. 

The  finger,  inserted  through  the  opening,  feels  for  stones, 
measures  their  size,  and  tells 
how  best  they  may  be  removed. 
For  their  removal,  Tait  uses 
special  scoops  and  forceps ;  and 
these  will  be  found  very  con- 
venient.    Small  stones  are 
scooped    out;    large  ones    are 
carefully  extracted  by  forceps. 
All  this   is  eas}^  enough  ;    but 
if  a  stone  is  impacted  in   the 
neck  of  the  gall-bladder,   and 
more  particularly  if  it  lies  some 
way  down  the  C3'Stic  duct,  ex- 
traordinary difficulties  may  be 
met  with.      It    must  never  be 
forgotten  that  the  walls  of  the 
bladder  and  its   ducts  are 
thin,  friable,  and  by   no 
means    dis  ten- 
sile ;    that     they 
may  very  easily 
be  torn  through  ; 
and  that,  if  such 
an  accident  hap- 
pens, the  result, 
as  creating  a  bil- 
iary fistula  open- 
ing into  the  peri- 


FiG.  76. 


Tait's  Cholelitliotomy  Forceps. 
One-ihiid  si.:e. 


THE   OPERATION.  607 

toneum,  will  almost  certainly  be  fatal.  Cholecystectomy  is  then 
the  only  resource.  Therefore,  all  manipulations  upon  impacted 
_gall-stones  must  be  carried  out  with  extreme  delicacy.  Tait's 
special  forceps  (Figs.  76  &  77)  are  here  invaluable.  If  the  stone 
cannot  readily  be  dislodged,  it  is  broken  into  fine  fragments  by 
nibbling  or  chipping  pieces  off  it  as  it  lies  in  situ.  During  this 
process  of  detrition,  one  forefinger  (the  right,  if  the  surgeon 
is  ambi-dextrous)  is  kept  over  the  stone  inside  the  abdomen,  to 
act  as  a  guide  and  as  a  guard,  and  perhaps,  when  it  has  been 
sufficiently  diminished  in  size,  to  start  it  from  its  bed  or  push  it 
between  the  blades  of  the  forceps.  During  these  manipulations 
there  may  be  some  bleeding  from  the  mucous  membrane. 

To  prevent  escape  of  fluid  into  the  abdominal  cavity,  and  to 
guide  it  towards  the  outside,  Musser  and  Keen  invented  and 
used  a  scoop  of  a  special  shape,  which  was  held  under  the 
gall-bladder  by  an  assistant.  A  sponge  is  quite  efficacious, 
however. 

If  a  stone  in  any  of  the  ducts  cannot  be  reached  by  forceps, 
and  cannot  easily  be  pushed  onwards  or  backwards  by  the 
fingers,  we  may  adopt  Tait's  ingenious  expedient  of  crushing 
it  by  carefully-padded  forceps  outside  the  duct-walls."'-'  The 
obvious  suggestion  of  trying  to  push  the  stone  onwards  by 
means  of  a  probe  has  been  made  by  several  writers ;  but  it  has 
not  been  successful,  nor  is  it  very  likely  to  be  so  if  the  stone  is  ot 
considerable  size.  Thornton  f  has  in  two  cases  succeeded,  after 
dilating  the  cystic  duct,  in  removing  from  the  common  duct 
calculi  which  caused  obstructive  jaundice.  J.  W.  Taylor-  ot 
Birmingham  succeeded  in  dislodging  a  stone  impacted  in  the 
cystic  duct  by  frequently  syringing  the  gall-bladder  with  hot 
water  through  the  fistulous  opening  left  after  cholecystotomy. 

Suturing  of  the  opening  in  the  gall-bladder  to  the  edges  ot 

the  parietal  wound  is  the  next  step.     The  sponge   inside  the 

abdomen  is  removed  ;  and  the  surface  of  the  bladder  carefully 

cleansed.     While  the  assistant  steadily  holds  the  opening  in  the 

bladder  in  the  position  where  it  is  to  be  fixed,  the  surgeon  passes 

*  Brit.  Med.  Joimi.,  July  12th,  1SS4.      f  Brit.  Med.  Journ.,  Nov.  2Gth,  18S7. 
\  Brit.  Med.  Journ.,  Jan.  21st,  1888. 


608  CHOLECYSTOTOMY. 

the  sutures.  The  best  mode  of\  suturing  is  that  favoured  by 
Tait — the  continuous  suture,  inckiding  skin,  parietal  peritoneum, 
and  cyst-wall.  Two  needles,  threaded  with  Chinese  twist  of 
medium  size,  are  used.  The  needle,  beginning  opposite  one 
extremity  of  the  bladder-wound,  is  passed  in  succession  through 
skin,  parietal  peritoneum,  and  gall-bladder,  and  so  continued  by 
separate  insertions  up  to  the  other  extremity.  The  same  is  done 
on  the  opposite  side.  Two  free  ends  of  the  two  continuous 
sutures  are  now  caught  up — one  pair  in  one  hand,  the  other  pair 
in  the  other  hand — and  pulled  sufficiently  tight  to  secure  accu- 
rate closure  all  round.  The  free  ends  above  and  below  may 
now  be  tied  together.  If  extra  sutures  are  necessary  to  close 
the  parietal  opening,  these  are  best  placed  before  suturing  the 
bladder ;  but  they  are  not  tied  till  the  last. 

A  rubber  drainage-tube  is  placed  in  the  bladder,  and  left 
protruding  through  the  parietal  opening.  Rubber  is  better  than 
an  unyielding  material,  because  of  the  movements  during  respi- 
ration. It  is  fixed  in  position  by  a  stitch  carried  through  the 
skin.  If  the  tube  fits  the  opening  accurately,  additional  finish 
may  be  given  to  the  operation  by  surrounding  it  with  a  sheet  of 
rubber,  as  in  drainage  after  ovariotomy ;  or  even  by  carrying  its 
imperforated  extremity  to  some  distance  from  the  wound,  and 
placing  it  in  a  bottle  which  lies  by  the  patient's  side.  By  this 
latter  plan  I  have  been  able  to  collect  all  the-^bile  which  escaped 
without  any  of  it  coming  into  contact  with  the  wound. 

An  ordinary  dressing  of  absorbent  material  is  applied,  and 
changed  as  frequently  as  may  be  necessary.  At  the  end  of  a 
week  the  sutures  are  removed.  The  drainage-tube  may  be  left 
longer  if  there  is  much  discharge,  or  if  the  cavity  it  drains  is 
large  and  has  not  greatly  diminished.  A  biliary  fistula  now 
remains,  which  will  probably  close  in  a  few  weeks  if  the  ducts 
are  pervious.  If  there  remains  an  obstruction  in  the  common 
duct,  the  whole  of  the  bile  will  be  discharged  through  the  fistula, 
and  attempts  to  close  it  will  fail.  In  such  cases,  if  Tait's  daring 
expedient  of  crushing  a  stone  left  in  the  duct  cannot  be  adopted. 
Winiwarter's*  plan  of  establishing  a  fistula  between  the  gall-  - 
*  Pra^.  Mediz.  Wocliensch.,  No.  21,  18S2. 


ENTERO-CHOLECYSTOTOMY.  609 

bladder   and    the    intestine    may   be    followed.      (See    Entero- 
cholecystotomy.) 

The  plan  of  complete  intra-peritoneal  closure  of  the  opening 
in  the  gall-bladder  may  be  dismissed  in  a  word.  Bobbs,  in  his 
case,  had  a  success,  though  he  used  only  one  suture.  Gross, 
whose  operation  was  a  sequence  to  nephrectomy,  cut  out  a 
piece  of  the  bladder  with  the  stone,  and  closed  the  opening  by 
sutures.  When  his  patient  died  from  the  effects  of  the  major 
operation,  the  wound  in  the  gall-bladder  was  found  to  be  closed. 
These  cases  prove  that  intra-abdominal  closure  may  be  suc- 
cessful. But  it  has  also  failed,  as  more  than  one  case  proves. 
But  primary  closure  of  such  a  cyst  has  been  proved,  in  other 
departments  of  abdominal  surgery,  to  be  not  so  safe  as  secondary 
closure  after  drainage.  And  special  risks  exist  in  the  case  of 
the  gall-bladder  ;  for  we  can  never  be  certain  that  the  ducts  are 
pervious  down  to  the  duodenum,  and  there  is  often  doubt  as  to 
the  complete  removal  of  calculi.  The  very  smallest  stone  left 
behind  may  be  a  source  of  subsequent  trouble.  It  is,  further,  a 
consideration  deserving  of  some  weight,  that  if  the  gall-bladder 
is  adherent  to  the  abdominal  wall,  any  stones  which  may  subse- 
quently form  can  be  safely  and  easily  evacuated  by  a  simple 
incision  through  the  old  scar. 


EXTERO-CHOLECYSTOTOMY. 

By  this  operation  is  meant  the  establishment  of  a  fistula 
between  the  gall-bladder  and  the  intestine.  The  operation  is 
indicated  only  in  cases  of  incurable  biliary  fistula — that  is,  in 
cases  where  there  is  insuperable  occlusion  in  the  ductus  com- 
munis choledochus.  The  original  operation  of  Winiwarter, 
already  referred  to,  successfully  established  a  communication 
between  the  gall-bladder  and  the  colon.  In  this  situation,  the 
physiological  effects  of  the  biliary  secretion  were  lost.  Dr. 
Gaston  of  Atlanta,  Georgia,*'  in  a  series  of  instructive  experi- 
ments on  dogs,  showed  how  a  communication  might  be  estab- 
lished between  the  duodenum  and  the  gall-bladder,  thus 
*  Atlanta  Med.  and  Surg.  Joiirn.,  Sept.  and  Oct.,  1SS2. 
40 


610  ENTERO-CHOLECYSTOTOMY. 

preserving  to  the  system  whatever  vakie  the  bile  may  have. 
Gaston  speaks  of  his  operation  as  duodeno-cholecystotom3\ 
Some  misconceptions  and  misdirected  criticims  of  Gaston's 
operation  have  appeared  in  various  journals  :  to  these  he  has 
given  satisfactory  answers.*  A  very  valuable  experimental  and 
literary  consideration  of  the  operation  has  been  contributed  by 
Francesco  Colzi  of  Florence,  f  Winiwarter's  operation  was 
colo-cholecystotomy :  Gaston  recommends  duodeno-cholecys- 
totomy  ;  and  this  operation,  where  it  is  easily  carried  out,  is 
theoretically  the  best.  But  fistula  with  the  upper  portion  of  the 
jejunum  would  be  scarcely  inferior  to  fistula  with  the  duodenum  ; 
and  fistula  with  any  part  of  the  jejunum,  or  even  ileum,  superior 
to  fistula  with  the  colon.  The  choice  ought  to  be  surgical  as 
well  as  physiological :  the  operation  may,  therefore,  be  properly 
described  as  entero-cholecystotomy. 

The  operation  has,  as  yet,  scarcely  passed  the  experimental 
stage.  Winiwarter,  not  satisfied  with  his  original  operation, 
recommends  the  following :  Some  portion  of  the  small  bowel,  as 
near  as  possible  to  the  duodenum  (the  duodenum  is  usually 
too  firmly  fixed),  is  stitched  to  the  gall-bladder  by  sutures  not 
penetrating  the  mucosa.  The  apposed  surfaces  are  joined  to 
the  abdominal  wound,  the  threads  uncut  being  left  hanging  out. 
In  five  or  six  days  adhesions  will  have  formed  between  the  gall- 
bladder and  the  intestine  :  the  fistula  is  made  by  incision  through 
the  centre  of  the  adherent  area,  and  the  edges  of  the  opening 
sutured,  and  a  tampon  inserted  to  prevent  closure.  Other  plans 
have  been  suggested. 

In  any  case  of  biliary  fistula  which  might  be  placed  under 
my  care,  I  would  be  inclined  to  try  the  following  plan :  (i) 
Abdominal  section  below  and  up  to  the  site  of  the  fistula. 
{2)  suture  of  a  convenient  portion  of  the  upper  intestine  to  the 
under  aspect  of  the  gall-bladder,  as  near  as  possible  to  the 
fundus  and  over  an  area  as  large  as  convenient.  These  sutures 
to  pass  through  the  serous  and  muscular  coats  only,  and  to 
extend  from  the  margin  of  the  fistula  at  least  an  inch  down- 

*  Med.  and  Surg.  Reporter,  Phila.,  Sept.  12th,  1885. 
t  Lo  Sperimentale,  fasc.  iv,,  v.,  1886. 


CHOLECYSTECTOMY.  611 

wards.  (3)  At  the  end  of  a  week  or  so,  perforation  of  the 
apposed  and  adherent  surfaces  by  a  cutting  operation.  This 
might  readily  be  done  through  the  abdominal  fistula,  and  would 
not  require  anaesthesia.  A  small  solid  bougie  of  rubber  or 
decalcified  bone  is  placed  in  the  opening,  and  left  for  a  few 
days  longer  till  it  has  become  a  fistula.  (4)  Blocking  of  the 
parietal  fistula  as  soon  as  the  fistula  between  gall-bladder  and 
bowel  has  been  established.  If  simple  mechanical  pressure  does 
not  succeed,  then  a  plastic  operation  might  be  performed.  Such 
an  operation,  though  somewhat  tedious,  is  not  dangerous  :  the 
whole  of  the  proceedings  are  carried  out  near  the  surface,  almost 
under  the  eye ;  and  it  follows  up  and  takes  advantage  of  per- 
fectly natural  processes  of  adhesive  inflammation  and  fistula- 
formation. 

CHOLECYSTECTOMY, 

or  removal  of  the  gall-bladder,  has  been  proposed  b}^  Langen- 
buch,  and  carried  out  by  him  in  twelve  cases.  Thiriar, "  Cour- 
voisier  and  Tillmannsf  have  adopted  the  operation.  In  22  cases 
collected  by  Depage  there  were  only  two  deaths  as  a  direct 
result  of  the  operation.  Thus  far  the  mortality  of  cholecystec- 
tomy (under  10  per  cent.)  is  more  favourable  than  that  of  chole- 
cystotomy  (over  15  per  cent.).  One  death  which  should  not  be 
reckoned  occured  in  Thiriar's  practice,  in  which  cerebral  tumour 
was  the  cause. 

The  idea  is,  to  remove  with  the  gall-bladder  all  future 
dangers,  such  as  may  arise  from  the  presence  of  calculi  in  it. 
It  is  a  fact  that  perfect  health  may  co-exist  with  absence, 
atrophy,  or  obliteration  of  the  gall-bladder.  Some  animals  have 
no  gall-bladder,  and  from  others  it  may  be  removed  without 
interfering  with  healthy  existence. 

Of  Langenbuch's  twelve  operations,  two  died — one  from 
ulceration  of  the  bile-duct,  caused  by  an  undetected  calculus. 
Seeing  that  Langenbuch  speaks  of  obstruction  in  the  common 
duct  as  a  contra-indication,  the  result  in  his  fatal  case  is  a  some- 

*  Rev.  dc  Chir.,  March,  1S86. 

t  Beilagc  zitm  Centyalbl.  f.  Chir.,  1S87,  xxv,,  p.  76. 

40  * 


612  CHOLECYSTECTOMY. 

what  severe  commentary  on  his  operation.  The  mere  fact  that 
we  cannot  be  certain  in  some  cases  that  there  is  no  stone  left 
behind,  is  a  strong  objection  to  the  operation.  In  a  goodly 
proportion  of  cases  of  cholecystotomy,  stones  have  appeared 
through  the  fistula  after  they  had  all  been  supposed  to  have 
been  removed.  It  is  not  so  much  the  death  as  the  immediate 
cause  of  it  that  speaks  against  the  operation.  Not  onl}^  does 
cholecystectomy  not  remove  every  nidus  for  biliary  calculi, 
but  it  greatly  adds  to  the  risk,  in  cases  of  lodgment  of  stones 
in  the  ducts,  b}^  cutting  off  one  avenue  of  escape.  To  seek  to 
establish  a  place  for  cholecystectomy  by  decr3'ing  the  advan- 
tages of  cholecystotomy  is  futile.  It  is,  however,  justifiable 
to  urge  against  the  performance  of  the  major  operation  the 
gratifying  success  of  the  minor  proceeding. 

The  indications  for  operation  given  by  Langenbuch  are, 
drops}',  cholelithiasis,  and  empyema.  These  indications  are 
probabl}'  too  broad.  I  should  limit  the  indications  to  two : 
(i)  where  the  bladder,  containing  one  or  more  calculi,  is  so 
contracted  that  its  fundus  cannot  be  sutured  to  the  parietes 
without  tearing  its  walls ;  (2)  where  there  has  been  perforation 
after  ulceration  and  empyema,  and  the  tissues  are  so  thin  or  so 
much  inflamed  that  they  will  not  bear  suturing. 

The  operation  need  not  be  difficult.  Separation  from  the 
liver  is  begun  at  the  fundus  of  the  bladder,  and  carried  down  to 
the  cystic  duct.  The  duct  is  divided  between  two  ligatures, 
and  the  bladder  removed.  A  suture  passing  through  the  outer 
coats  will  more  thoroughly  close  the  divided  end  of  the  duct. 
The  incision  will  be  at  least  an  inch  and  a  half  longer  than  in 
cholecystotomy ;  if  additional  room  is  wanted,  Courvoisier's 
plan  of  dividing  transversely  the  muscles  a  little  below  the  ribs 
may  be  adopted.  If  the  bladder  is  intimately  attached  to  the 
liver,  a  good  deal  of  haemorrhage  may  be  expected  :  most  of  the 
bleeding  may  be  checked  by  forci-pressure,  but  a  few  ligatures 
may  be  called  for.  During  the  operation  the  edge  of  the  liver 
is  pulled  upwards  by  a  retractor,  and  the  area  of  operation  is 
isolated  by  means  of  sponges. 

If  removal  of  the  bladder  cannot,  in  whole  or  in  part,  be 


CHOLECYSTECTOMY.  613 

effected,  ligature  of  the  cystic  duct  has  been  suggested.  It  is 
difficult  to  see  how  this  can  be  more  beneficial  than  total 
occlusion  of  the  duct  from  pathological  causes.  As  the  gall- 
bladder not  only  acts  as  a  receptacle  for  bile,  but  also  secretes  a 
mucous  fluid  which  probably  contains  a  ferment,  mere  ligature 
of  the  duct  does  not  seem  to  promise  much  benefit.  Zelewicz* 
has  had  a  successful  case  of  ligature  of  the  cystic  duct  after 
cholecystotomy. 

Free  bilateral  incision  of  the  gall-bladder,  followed  by  suture 
and  return  to  the  cavity,  has  been  recommended  by  Kiister  of 
Berlin,  and  carried  out  by  him  and  Tillmanns  of  Leipzig.  In 
suppuration  of  the  bladder,  removal  of  redundant  portions  of 
tissue  may  be  of  advantage,  and  the  same  may  be  true  of 
enormous  cystic  distensions ;  but  it  is  difficult  to  see  how  the 
chances  of  recovery  are  removed  by  mere  incision  with  sub- 
sequent suture. 

*  Ccntralbl.  f.  Chiv.,  No.  13,  1888. 


Section  X, 


OPERATIONS    ON    THE    SPLEEN. 


The  operations  performed  on  the  spleen  are — Splenotomy,  or 
incision  through  the  organ ;  and  Splenectomy,  or  removal  of  it. 
It  happens  that  the  term  splenotomy  has  been  extensively 
employed  for  extirpation  of  the  spleen  ;  splenectomy  has  only 
recently  come  into  general  use,  in  its  proper  sense.  Splenotomy, 
or  splenic  incision,  must  always  be  a  rare  operation  :  as  being 
so,  and  as  presenting  no  special  features  calling  for  description, 
the  present  account  is  practically  confined  to  splenectomy,  or 
extirpation  of  the  spleen. 

Surgical  Anatomy. — The  spleen,  lying  in  the  left  hypochondriac 
region  between  the  cardiac  end  of  the  stomach  and  the  under 
surface  of  the  diaphragm,  is  roughly  moulded  to  fit  the  space  in 
which  it  lies ;  being  concave  on  the  stomachic  aspect,  and  con- 
vex  on   the   diaphragmatic.      On   the   concave   inner   surface, 


SURGICAL   ANATOMY  OF  THE   SPLEEN. 


615 


nearer  to  the  posterior  than  the  anterior  border,  is  the  vertical 
groove  of  the  hilum,  pierced  by  apertures  for  vessels  and 
nerves.  The  peritoneum  which  invests  the  spleen  is  reflected 
at  the  hiluni  to  enclose  the  splenic  vessels  and  nerves  and  the 

vasa  brevia,  and  is 
1  __...,  known  as  the  gastro- 

splenic  omentum. 
Surgically,  this  is 
the  pedicle  of  the 
spleen.  (Fig.  78.) 
Between  the  up- 
per end  of  the 
diaphragm  passes 
another  double  peri- 
toneal layer,  known 
as  the  suspensory 
ligament  of  the 
spleen.  The  exter- 
nal surface  of  the 
spleen,  in  con- 
tact with  the 
diaphragm,  is  des- 
cribed as  lying  in 
contact  with  the 
ninth,  tenth,  and 
eleventh  ribs.  The 
internal  surface,  in 
its  anterior  por- 
tions, is  in  relation 
with  the  c  a  r  d  i  a 
of  the  stomach — 
behind,  with  the 
left  crus  of  the  diaphragm  and  the  left  supra-renal  capsule ; 
and  below,  with  the  tail  of  the  pancreas.  Its  relations  with 
the  stomach  are  liable  to  be  disturbed  by  the  movements  of  that 
organ.  As  to  the  margin  of  the  spleen :  at  the  top,  where  the 
suspensory  ligament  is  given  off,  it  is  blunt  and  rounded ;  the 


Fig.  78.     (Weisse). 

Drawing  to  show  the  uessels  in  the  Hilum  of 
the  Spleen. 

1,  2.  Vessels  penetrating  the  Spleen  at  the  Superior,  and 
4,  the  Inferior  Extremities  of  the  Hilum.  3,  5,  7.  Gastric 
iiranches  —  Vasa  Brevia.  6.  Gastro-epiploica  Sinistra. 
Anterior  Border  to  right,  Superior  Border  above.  Artery 
above,  Vein  below. 


616  OPERATIONS  ON   THE  SPLEEN. 

lower  extremity  is  pointed,  and  normally  lies  over  the  junction 
of  the  transverse  with  the  descending  colon  ;  the  posterior  mar- 
gin is  broad  and  rounded,  and  is  connected  with  the  left  kidney 
by  loose  areolar  fibres.  The  average  dimensions  of  the  spleen, 
in  the  adult,  are :  five  inches  in  length,  three  or  four  in  breadth, 
and  from  an  inch  to  an  inch  and  a  half  in  thickness.  Its  weight 
is  about  seven  ounces. 

The  structures  in  the  gastro-splenic  omentum,  venous  and 
arterial,  which  go  to  form  the  pedicle  in  splenectomy  are  of 
importance.  The  splenic  artery,  the  largest  branch  of  the 
cceliac  axis,  pursues  a  tortuous  course  behind  the  upper  border 
of  the  pancreas  from  the  aorta  to  the  spleen.  In  its  course  it 
gives  off  small  branches  to  the  pancreas;  near  its  termination  it 
gives  off  the  gastro-epiploica  sinistra ;  and  it  finally  breaks  up 
into  a  number  of  branches  near  the  hilum,  most  of  which  enter 
it,  but  a  few  of  which — the  vasa  brevia — turn  backwards 
to  the  stomach.  The  vasa  brevia,  from  five  to  seven  in 
number,  issue  partly  from  the  trunk  and  partly  from  the 
branches  of  the  splenic  artery.  If  deligation  is  made  close  to 
the  spleen,  they  may  escape.  The  terminal  branches  are  five, 
six,  or  more  in  number,  and  vary  greatly  in  length  and  size. 
If  the  branches  are  short,  and  they  enter  the  spleen  over  a  con- 
siderable area,  it  would  be  impossible  to  include  all  of  them  in 
one  or  even  in  two  ligatures. 

The  splenic  vein  is  a  very  large  vessel,  returning  blood,  not 
only  from  the  spleen  and  the  pancreas,  but  also  from  the  duo- 
denum, a  great  part  of  the  stomach  and  omentum,  the  descending 
colon,  and  part  of  the  rectum.  Its  splenic  branches  correspond 
to  those  of  the  artery ;  the  vein  itself  lies  behind  the  pancreas, 
below  the  artery. 

But  little  padding  of  fatty  or  areolar  tissue  surrounds  the 
splenic  vessels  at  the  hilum.  As  it  would  usually  be  unsafe  to 
include  all  the  splenic  branches  in  one  ligature,  it  is  fortunate 
that  they  may  readily  be  isolated  and  ligatured  separately. 

History  of  Splenectomy. — The  practice  of  removing  the  spleen 
is  probably  of  some  antiquity.     It  was  done  for  purposes  suffi- 


HISTORY.  617 

ciently  vague,  being  supposed  to  improve  the  wind  of  the 
individual  (as  in  the  Texan  runners),  or  to  amehorate  his  moral 
nature.  Dionis,  in  his  second  demonstration  of  surgical  opera- 
tions (1733),  speaks  of  a  class  or  sect  of  surgeons  which  sprang 
into  notoriety  about  1700  from  their  operations  of  removing  the 
milt  or  spleen — "  unmilting  "  the  proceeding  was  called.  He 
does  not  spare  them  :  "  They  looked  on  this  part  as  useless  and 
noxious,  because  (perhaps)  unacquainted  with  its  uses  ;  and,  in 
pursuit  of  this  opinion,  they  prescribe  the  making  an  incision  in 
the  left  hypochondrium,  through  which  they  take  out  the  milt, 
and  after  having  made  a  ligature  of  the  vessels,  boldly  cut  it  off. 
This  operation  being  performed  on  some  dogs  which  did  not 
thereupon  die  on  the  spot,  they  thence  deduced  and  proclaimed 
the  advantages  which  would  accrue  to  mankind  by  it.  .  . 
No  longer  mention  is  made  of  these  cruel  operations,  which 
owing  their  existence  to  some  crude  brains,  found  a  sepulture  in 
that  of  their  inventors." 

For  prolapse  of  the  spleen  through  a  parietal  wound  splen- 
ectomy was  performed  more  than  200  years  ago.  Such  an 
operation  was  that  of  Matthias,  performed  in  1678  ;'■'  and  a  few 
others  are  on  record. f 

Many  experiments  have  been  made  on  the  lower  animals  by 
removing  the  spleen.  In  comparatively  recent  times,  Blundell 
operated  at  least  seven  times  on  rabbits ;  two  recovering  per- 
manently, and  two  temporarily.  The  whole  subject  has  been 
experimentally  gone  into,  with  all  the  aids  of  modern  science, 
by  numerous  physiologists  and  surgeons,  and  notably  by 
Tizzoni,  Mosler,]:  Zesas,i  and  Winogradoff.  [  These  experi- 
ments prove  that  the  spleen  is  not  essential  to  the  life  of  animals ; 
and  that  if  it  is  removed,  its  functions  are  taken  up  by  vicarious 
lymphatic  organs  which  increase  in  size,  and  by  bone-marrow. 

For  disease,  the  first  operation,  according  to  Collier,*  was 

*  See  Simon,  Die  Extirpation  dev  MHz  am  Menschcn.     Giessen.,  1857. 

t  See  Morris,  Internat.  Syst.  of  Siiyg.,  vol.  v.,  "  Injuries  and 

Diseases  of  the  Abdomen." 

I  Deutsch,  med.  l7oc/;,,  1884,  No.  22.     §  Langenbeck's  ^rf/uV.,  bd.  xxviii.,  p.  815. 

I    Revue  de  Chir.,  1885,  p.  318;  quoted  from  Vratch,  1883,  Nos.  6  and  7. 

^f  Lancet,  1882,  i.,  p.  219. 


618  OPERATIONS   ON   THE  SPLEEN. 

performed  by  Zaccarelli  in  1549,  and  was  successful.  The 
second  operation,  by  Ferrerius  in  171 1,  seems  to  have  been  the 
removal  of  a  rudimentary  spleen  from  an  abscess  tending  to 
point ;  it  was  also  successful.  Both  these  operations  have  been 
discredited.  Quittenbaum  in  1826,  and  Kuchler  in  1855,  each 
removed  an  enlarged  spleen  ;  the  patients  in  each  case  dying  in 
a  few  hours,  of  haemorrhage.  Spencer  Wells  operated  for  simple 
hypertrophy  in  1865  :  his  patient  lived  six  days,  and  died  either 
of  thrombosis  or  of  blood-poisoning — possibly  of  both.  Pean  in 
1867,  operating  for  enlarged  and  cystic  spleen,  had  the  first 
success  of  modern  times  :  from  his  case  we  may  date  the  intro- 
duction of  splenectomy  into  modern  surgery. 

Conditions  for  which  Splenectomy  may  he  Performed. — Nearly  all 
authorities  are  agreed  that  the  extirpation  of  leucocythaemic 
spleen  is  an  unjustifiable  operation.  Therefore,  although  the 
operation  has  been  performed  some  eighteen  times,  leucocythae- 
mic enlargement  is  excluded  from  the  conditions  justifying  opera- 
tion.    The  following  conditions  remain  : 

(i)  Injury  or  Prolapse. 

(2)  Certain  cases  of  movable  spleen. 

(3)  Simple  hypertrophy,  with  or  without  cirrhosis. 

(4)  Sarcoma  or  lympho-sarcoma  in  the  early  stages. 

(5)  Cysts. 

(6)  Hj^datid  disease. 

In  the  case  of  abscess,  as  well  as  of  cysts,  simple  and  hydatid,, 
splenotomy,  or  incision  of  the  spleen  with  suture  of  the  wound 
to  the  parietes  and  drainage,  should  first  be  instituted.  The 
treatment  is  carried  out  on  exactly  the  same  lines  as  for  similar 
diseases  of  the  liver  or  kidney,  and  need  not  be  again  detailed. 
Should  splenotomy  fail  to  cure,  splenectomy  may  be  indicated. 
Splenic  abscess  becomes  early  adherent  to  the  parietes,  and  its 
treatment  ma}'  be  nothing  more  than  incision  and  drainage. 
From  such  an  abscess  I  have  seen  a  piece  of  splenic  tissue,  as 
large  as  an  orange,  removed  as  a  slough. 

Woimds  of  the  spleen  can  only  be  inferred  with  a  presump- 


INDICATIONS  FOR   OPERATION.  61  ^ 

tion  of  certainty  from  the  site  of  the  injury  and  the  presence  of 
abdominal  haemorrhage.  Later  on,  peritonitis,  splenitis,  and 
abscess  may  supervene,  and  induce  symptoms  calling  for  ab- 
dominal section,  after  which  the  condition  is  diagnosed  with 
certaint3\  In  such  cases,  the  state  of  the  patient  is  the  indi- 
cation to  operate  :  splenic  wounds  are  by  no  means  always  fatal. 
Prolapse  of  the  spleen  through  a  parietal  wound  is  easily 
diagnosed  :  in  certain  cases,  the  organ  may  be  returned  ;  in 
others,  only  the  protruding  part  need  be  removed. 

Movable  spleen,  according  to  Engel,"^  is  associated  with 
pregnane}^  depending  on  causes  similar  to  those  assigned  by 
Landau  to  movable  kidney.  It  is  not  free  from  danger  to  life. 
Reported  cases  show  that  a  movable  spleen  tends  to  fall  into 
the  left  iliac  fossa ;  that  the  organ  is  enlarged ;  that  its  pedicle 
may  become  twisted,  causing  occlusion  of  the  vessels ;  and  that 
it  has  a  tendency  to  contract  adhesions  in  its  abnormal  situation, 
and  there  undergo  degenerative  changes,  or  even  gangrene. 
Serious  symptoms  may  be  caused  by  dragging  on  the  stomach 
through  the  gastro-splenic  ligament. 

Simple  hypertrophy,  with  and  without  cirrhosis,  has,  in  at 
least  fourteen  cases,  been  given  as  the  reason  for  removal.  It  is 
difficult  from  the  histories  to  estimate  the  influence  of  malarial 
disease  in  causing  the  enlargement  for  which  operation  was  per- 
formed. The  diagnosis  is  simply  that  of  enlarged  spleen,  already 
described  :  in  most  cases,  however,  the  operation  was  performed 
in  the  belief  that  the  disease  was  something  else. 

Billroth f  has  successfully  removed  the  spleen  for  lympho- 
sarcoma. The  tumour  had  existed  for  seven  years :  there  was 
no  leukaemia.  It  would  be  impossible  in  the  early  stages  to 
diagnose  malignant  disease  from  simple  enlargement.  When 
the  disease  is  so  far  advanced  as  to  cause  adhesions  to  neigh- 
bouring organs,  the  operation  is  unjustifiable.  Indeed,  from 
what  we  know  of  the  behaviour  of  malignant  disease  of  the 
spleen,  we  should  infer  that  the  operation  was  only  very  excep- 
tionally admissible. 

Considering  the  rarity  of  cysts  of  the  spleen,  it  is  somewhat 
*  Centnilhl.  f.  Gynak.,  iSS6,  V.         t  Lancet,  June  yth,  1S84. 


€20  OPERATIONS   ON   THE   SPLEEN. 

remarkable  that  the  organ  should  have  been  three  times  re- 
moved for  that  disease.  All  the  operations  were  successful. 
Thornton's  first  operation — the  first  successful  one  in  England — 
was  for  splenic  cyst.  The  diagnosis  cannot  with  certainty  be 
made  from  renal  cyst.  Puncture,  or  incision  with  drainage, 
might  be  tried  before  removing  the  organ.  As,  however,  the 
cystic  disease  is  usually  associated  with  hypertrophy  of  the  splenic 
tissue,  it  is  probable  that  the  cyst-formation  is  only  part  of  a 
more  general  disease.  In  none  of  the  operations  was  the  condi- 
tion diagnosed  till  the  abdominal  cavity  was  entered. 

For  h3'datid  disease,  puncture  has  been  successfully  per- 
formed by  Wilde,  '■'  and  probably  by  others.  Koeberle  has 
extirpated  the  organ  for  hydatid  disease  followed  by  a  sanious 
discharge.     The  diagnosis  must  always  be  uncertain. 

Appreciation  and  Mcvtality.  Indications  and  Contva-indications. — 
Collier's  elaborate  tables  comprise  29  cases  of  splenectomy;  13 
being  for  diseases  not  associated  with  leucocythaemia — of  these  8 
recovered  ;  16  for  leucocj^theemic  hypertrophy — all  these  died. 
So  far,  there  would  appear  to  have  been  performed  only  one 
successful  operation  for  leucocythaemic  spleen — that  of  Franzolini 
of  Turin — and  this  case  is  doubtful,  f  Ashurst:]:  has  collected  43 
splenectomies  for  disease,  with  31  deaths;  and  21  operations  for 
injury  or  prolapse — all  successful.  Nussbaum,  however,  of  26 
cases  for  traumatic  causes,  found  that  only  16  recovered. 
Gilson,  §  in  a  careful  review  of  the  whole  subject,  quotes  18 
operations  for  injury,  with  recovery  in  all ;  and  37  for  disease, 
with  29  deaths  and  8  recoveries.  Podrez  of  Kharkoff  estimates 
the  total  mortality  as  73  per  cent.  Molliere  ||  has  tabulated  28 
cases  of  laparo-splenectomy  for  disease,  and  11  cases  of  splen- 
ectomy for  wound,  with  results  accordmg  with  the  above. 
Wright  of  Manchester^  has  collected  and  tabulated  62  cases  of 
splenectomy.      Of  these,  22  were  for  leukaemia — all  were  fatal ; 

*  Deutsche  ArcJiiv.,  viii.,  116. 

■\  Wien.  meet.  Woch.,  1883,  No.  20.  \  Intevnat.  Encyc.  Surg.,  vol.  v.,  p.  1103. 

§  Rev.  de  Chiv.,  April  loth,  1885. 

II  Diet.  Encyc.  des  Sc.  Med.,  1883,  Art.   "  Splenotomie." 

*\  Med.  Chron.,  Dec,  1888. 


INDICATIONS  FOR   OPERATION.  621 

23  were  for  simple  hypertrophy — 15  died  ;  7  were  for  malarial 
disease — 5  recovered  ;  and  3  for  cystic  disease — all  recovered. 
Asch-'"  has  collected  go  cases:  of  these  51  were  successful  (14 
were   for   wandering   spleen). 

A  dissection  of  the  figures  according  to  the  causes  of  opera- 
tion shows  that  the  removal  of  prolapsed  or  v/ounded  spleen  is 
not  only  a  justifiable  but  a  successful  operation  ;  and  that  the 
removal  of  leucocythaemic  spleen,  even  if  it  gave  promise  of  a 
cure  of  the  disease,  is  negatived  by  its  almost  uniform  fatalit}-. 
Experience  has  shown  that  in  leucocythsemia  there  is  a  marked 
tendency  to  haemorrhage  after  operations  of  anj'  sort ;  and  this 
tendency,  in  such  an  operation  as  splenectomy  where  haemor- 
rhage is  always  a  chief  risk,  is  enough  to  forbid  it.  Besides,, 
there  is  no  reasonable  ground  for  inferring  that  removal  of  the 
spleen  would  have  an}'  influence  for  good  on  the  general  disease. 
Splenectomy  in  leucocythsmia  is,  as  Bryant  puts  it,  "  physio- 
logically unsound  and  surgicall}' unsafe  "  :  it  ought,  therefore,  to 
be  abandoned.  In  Franzolini's  case — the  only  one  reported  as 
successful — the  spleen  was  not  very  large  (61  oz.)  ;  and  the  last 
report  of  it,  when  the  blood  was  said  to  be  normal,  was  only  four 
months  after  operation. 

For  disease  not  attended  with  leucocythaemia,  the  operation 
is  at  least  justifiable.  For  undue  mobility  the  operation  has 
been  most  successful ;  for  cystic  disease  the  operation  has  been 
very  successful ;  while  for  such  conditions  as  lympho-sarcoma, 
simple  hypertrophy,  hypertrophy  with  cirrhosis,  hydatids  and 
abscess,  the  failures  have  about  equalled  the  successes. 

The  present  position  of  splenectomy,  therefore,  is  something 
like  the  following  :  Operations  for  leucocythsemic  spleen  are  un- 
justifiable. Operations  for  traumatic  lesions  are  justifiable  and 
safe.  For  movable  spleen,  excision  ought  not  to  be  carried  out 
till  less  severe  measures,  such  as  mechanical  support  or  operative 
fixation,  have  been  tried  and  found  ineffectual.  For  cysts,  the 
spleen  may  be  removed  with  a  fair  chance  of  success ;  but 
puncture  or  incision,  with  drainage,  ought  to  have  a  trial  first. 
In  the  early  stages  of  malignant  disease  the  operation  is  justi- 
*  Abstr.  in  Internal.  Journ.  Med.  Sc,  Nov.,  iSSS. 


€22  OPERATIONS   ON   THE   SPLEEN. 

fiable.  In  the  rare  cases  of  primary  hypertrophy,  the  operation 
is  permissible  if  the  disease  is  attended  with  danger  or  serious 
discomfort. 

THE    OPERATION    OF    SPLENECTOMY. 

The  incision  in  most  of  the  operations  has  been  made  in  the 
middle  line.  This,  no  doubt,  is  a  result  of  erroneous  diagnosis, 
and  not  of  operative  election.  A  lateral  incision  along  the 
outer  edge  of  the  left  rectus  would  probably  be  the  most 
convenient.  It  would  certainly  be  so  in  all  cases  not  attended 
with  great  enlargement.  Kiichler  and  Wells  made  the  entrance 
through  the  linea  semilunaris ;  Bryant,  a  little  farther  to  the 
outside.  In  prolapse,  the  wound  may  or  may  not  require 
enlargement. 

The  tumour  being  fully  exposed,  all  adhesions  are  divided 
and  ligatured.  It  is  gently  delivered,  lower  extremity  first.  If 
the  tissue  is  not  ver}^  friable,  the  use  of  Tait's  myoma  screw 
will  be  of  advantage.  Sponges  are  packed  inside  the  cavity  ; 
and  the  parietes  are  depressed  as  much  as  possible  by  an 
assistant,  to  prevent  traction  on  the  pedicle.  The  tumour  must 
be  handled  with  extreme  gentleness  ;  and  the  most  scrupulous 
care  must  be  given  to  the  avoidance  of  injury  to  the  vessels  in 
the  pedicle,  and  even  to  dragging  on  them,  which  has  been 
found  to  produce  alarming  symptoms  of  shock. 

The  success  or  failure  of  the  operation  may  be  truthfully 
said  to  depend  on  the  treatment  of  the  pedicle.  Death  from 
haemorrhage  after  a  few  hours  has  frequently  occurred,  after 
what  seemed  to  be  the  most  perfect  deligation  at  the  hands  of 
our  most  skilled  operators.  A  small  artery  slips  from  the 
encircling  ligature  (as  in  Thornton's  second  case) ;  or  a  ligature 
slips  during  straining ;  or  bleeding  may  commence  from  the 
moment  the  patient  begins  to  rally  from  the  shock.  It  is  clear, 
therefore,  that  our  surgical  technique  in  this  part  of  the  opera- 
tion is  by  no  means  perfect. 

Morris  •'■  recommends  that,  before  cutting  away  the  tumour, 
a  clamp  should  be  placed  around  the  pedicle,  and  that  it  should 
*  Inteynat.  Eiicyc.  Siw^.,  vol.  v.,  p.   1104 


SPLENECTOMY.  623 

afterwards  be  ligatured  in  two  or  more  parts  with  strong  twisted 
silk  or  whipcord.  Thornton,  in  his  successful  operation,  tied 
the  pedicle  in  two  locked  ligatures,  and  added  a  separate 
ligature  carried  round  the  whole.  In  his  unsuccessful  case,  he 
placed  three  locked  ligatures  by  double  transfixion,  tying  the 
outer  loop  first,  then  the  inner,  and  finally  the  middle  one. 
Temporary  forci-pressure  was  also  employed ;  yet  death  oc- 
curred from  haemorrhage  in  a  few  hours.  Thornton,  somewhat 
hypercritically  (as  it  seems  to  me),  blames  himself  for  having 
tied  the  middle  ligature  last.  Billroth  was  able  to  ligate  artery 
and  vein  separately  ;  but  in  this  case  he  must  have  passed  the 
ligature  farther  away  from  the  spleen  than  is  usually  possible — 
a  supposition  which  seems  the  more  likely,  as  he  removed  a  por- 
tion of  the  pancreas  with  the  tumour.  Franzolini  also  was 
able  to  put  a  ligature  on  the  artery,  which  was  the  size  of  the 
forefinger,  and  another  on  the  vein,  which  was  the  size  of  the 
thumb  ;  in  his  case,  it  was  specially  noted  that  the  pedicle  was 
short.  The  gastro-splenic  ligament  was  also  surrounded  in  two 
ligatures,  and  the  suspensory  ligament  in  one.  Simmons,  in 
America,  ligatured  tlae  pedicle  and  the  gastro-splenic  ligament 
separately  and  in  sections :  the  patient  died,  from  hasmorrhage 
in  two  and  a  half  hours.  Langley  Browne'^'"  found  no  proper 
pedicle,  but  four  very  large  arteries,  each  of  which  he  secured 
separately  by  double  ligatures,  dividing  them  between :  there 
was  no  haemorrhage ;  but  the  patient  died,  in  five  hours,  of 
shock. 

No  absolute  rule  can  be  laid  down  as  to  the  management  of 
the  pedicle ;  but  a  few  guiding  principles  may  safely  be  enunci- 
ated. Every  divided  vessel,  artery,  or  vein  should  be  efficiently, 
and  as  far  as  possible  separately,  ligatured.  The  ligature  should 
be  tied  while  the  pedicle  is  in  a  state  of  relaxation  :  the  tendency 
of  a  small  branch  to  retract  after  being  forcibly  elongated  is 
thereby  obviated.  The  veins  should  be  ligatured  as  well  as  the 
arteries,  because  considerable  branches  communicate  with  the 
splenic  vein  close  to  the  site  of  ligation.  If  the  splenic  branches 
spread  out  considerably  before  entering  the  hilum ;  if  they  are 
*  Lancet,  ii.,  1877,  p.   310. 


624  OPERATIONS   ON   THE  SPLEEN. 

numerous  and  intermingled  with  veins,  and  not  easily  isolated ; 
and  if  the  pedicle  is  not  short,  the  placing  of  a  broad  temporary 
clamp  before  cutting  away  the  tumour  may  be  found  advan- 
tageous. In  many  cases  it  will  be  found  a  good  plan  to  apply 
pressure  forceps  in  pairs — one  pair  after  another — to  each  por- 
tion of  the  pedicle  which  contains  a  vessel,  and  divide  between 
them  till  the  whole  pedicle  has  been  cut  through.  Then  one 
forceps  after  another  is  picked  up,  and  the  vessel  or  vessels 
which  it  grasps  are  deliberately  tied  at  a  safe  distance  from  the 
forceps.  When  each  vessel  has  been  secured,  the  whole  may 
be  surrounded  with  a  single  ligature,  tied  with  moderate  force, 
so  as  to  lessen  the  shock  of  the  arterial  pulse  on  the  distal  liga- 
tures. F'inally,  the  ligatures  are  all  cut  short,  and  the  pedicle 
dropped  into  the  cavity.  Sponging,  if  it  is  necessary,  should 
avoid  the  pedicle,  which  may  be  kept  out  of  the  way  by  a 
catch-forceps  attached  to  its  extremit}'. 

The  gastro-splenic  and  diaphragmatic  ligaments  are  dealt 
with  in  the  same  fashion  by  separate  ligatures;  the  same  minute 
care  need  not  be  observed,  however.  Adhesions  are  treated 
according  to  ordinary  principles. 

The  great  risk  of  the  operation  is  haemorrhage  from  the 
pedicle.  Of  the  29  cases  collected  by  Collier,  14  died  directly 
from  haemorrhage,  and  7  from  other  causes,  such  as  thrombosis 
(i  case),  peritonitis  (2  cases),  shock  (3  cases).  Shock  is  often 
very  alarming,  and  has  appeared  during  the  performance  of 
the  operation,  specially  while  traction  is  being  exerted  on  the 
pedicle. 


Section  XL 


OPERATIONS   ON   THE   PANCREAS. 


The  surgery  of  the  pancreas  has  not  as  yet  advanced  much 
beyond  the  tentative  or  experimental  stage.  The  elaborate 
studies  of  Dr.  N.  Senn,"^'  of  IMilwaukee,  exhaust  what  is  known 
of  the  operative  treatment  of  diseases  of  the  pancreas,  and  fix 
a  starting-point  in  their  description  from  which  all  future  work 
must  take  its  departure.  Treiberg  of  Nickolaiev  and  Lardy  for 
Kocher  of  Berne  I  have  recently,  by  reports  of  cases  and  examin- 
ation of  the  literature  of  the  subject,  added  to  our  knowledge. 
Treiberg  also  has  made  elaborate  experiments  with  a  view  to 
discover  what,  if  any,  serious  effects  follow  the  withdrawal  of 
the  pancreatic  secretion  from  the  economy. 

*  The  Suvf^cry  of  the  Pancreas.     Phila.,  1886.     "  The  Surgical  Treatment  of 
<jysts  of  the  Pancreas,"  Amer.  Joiirn.  Med  Sc,  July,  1885. 

t  Leader  in  Annals  of  Siii-geyy,  Nov.,  1888. 
41 


626  OPERATIONS   ON   THE   PANCREAS. 

Surgical  Anatomy  of  the  Pancreas. — The  pancreas  lies  deeply  in 
the  abdomen,  at  the  level  of  the  first  lumbar  vertebra.  Its  head 
lies  in  the  concavity  of  the  duodenum  ;  its  tail  lies  in  contact 
with  the  spleen.  It  can  be  reached  and  exposed  to  sight  by 
division  of  the  gastro-colic  omentum,  and  by  pulling  the  colon 
and  the  stomach  apart.  In  the  epiploic  sac  thus  opened,  the 
pancreas  is  seen  lying  on  the  large  abdominal  vessels.  The 
stomach  lies  in  contact  with  its  anterior  surface,  from  which  it 
is  separated  by  a  covering  from  the  "  omental  bursa."  The 
posterior  surface  rests  on  the  vena  cava,  the  aorta,  the  superior 
mesenteric  vessels  sometimes  surrounded  by  gland  tissue,  and 
the  pillars  of  the  diaphragm.  Towards  the  right  extremity,  it 
is  in  relation  with  the  vena  portae.  Each  extremity  of  the  pan- 
creas lies  surrounded  by  numerous  l3-mphatic  vessels  and  glands, 
embedded  in  areolar  tissue.  The  inferior  surface  rests,  at  one 
end,  on  the  junction  of  the  jejunum  and  duodenum  ;  at  the 
other,  on  the  transverse  colon.  The  middle  portion  of  the 
inferior  surface  has  a  special  peritoneal  covering,  derived  from 
the  lower  layer  of  the  meso-colon.  At  the  upper  border,  and 
behind  the  posterior  surface,  are  found  the  splenic  artery  and 
vein. 

Just  above  the  pancreas  lies  the  coeliac  axis.  The  common 
bile-duct  passes  behind  the  head  of  the  pancreas,  close  to  it  and 
sometimes  embedded  in  itS- tissue.  The  pancreatic  duct  unites 
with  the  common  bile-duct  in  the  wall  of  the  intestine,  at  the 
junction  of  the  second  and  third  portions  of  the  duodenum  and 
three  or  four  inches  below  the  pyloric  orifice  of  the  stomach. 

The  pancreas  receives  its  blood-suppl}^  from  the  pancreatico- 
duodenal branches  of  the  hepatic  and  superior  mesenteric 
arteries. 

Conditions  for  zvliich  Operation  may  he  Performed  on  the  Pancreas. — 
Billrotli'^''  has  successfully  removed  the  pancreas  for  cancer  :  the 
report,  however,  is  too  recent  to  make  certain  that  the  patient 
is  free  of  the  disease.  Removal  of  the  pancreas  for  primary 
malignant  disease  can,  however,  be  very  rarely  a  justifiable 
*    U'ien.  Died.  IVocIi.,  April  3rd,  1SS4. 


INDICATIONS  FOR   OPERATION.  627 

operation.  When  It  has  come  within  the  range  of  physical 
diagnosis,  It  will  have  invaded  the  adjacent  organs  and  tissues 
to  such  an  extent  that  removal  would  be  either  Impossible  or 
exceedingly  dangerous.  The  case  In  which  Billroth  removed  a 
portion  of  the  tail  of  the  pancreas  with  a  splenic  tumour  has 
already  been  referred  to.  To  remove  the  head  of  the  pancreas, 
It  would  be  necessary  to  leave  Intact  the  pancreatic  duct — a 
proceeding  scarcely  possible. 

Laborderle*  Is  said  to  have  successfully  removed  a  portion 
of  the  pancreas  protruding  through  a  wound  In  the  parletes. 
This  operation  has,  however,  been  discredited. 

Further  Indications  to  operate  are  given  by  Senn  as  follows : 

"  Partial  excision  of  the  splenic  portion  of  the  pancreas  is 
Indicated  in  cases  of  circumscribed  abscess  and  malignant 
tumours.  In  all  cases  where  the  pathological  product  can  be 
removed  completely  without  danger  of  compromising  pancreatic 
digestion  or  inflicting  abdominal  Injury  upon  important  adjacent 
organs, 

"  Ligation  of  the  pancreas  at  a  point  or  points  of  section 
should  precede  extirpation,  as  a  prophylactic  measure  against 
troublesome  haemorrhage  and  extravasation  of  pancreatic  juice 
into  the  peritoneal  cavity. 

"  The  formation  of  an  external  pancreatic  fistula  by  ab- 
dominal section  Is  Indicated  in  the  treatment  of  cj'sts,  abscesses, 
gangrene,  and  haemorrhage  of  the  pancreas  due  to  local  causes. 

"  Abdominal  section  and  lumbar  drainage  are  Indicated  In 
cases  of  abscess  or  gangrene  of  the  pancreas  where  It  is  found 
Impossible  to  establish  an  anterior  abdominal  fistula. 

"  Through  drainage  Is  Indicat^ed  in  cases  of  abscess  and 
gangrene  of  the  pancreas,  with  diffuse  burrowing  of  pus  in  the 
retro-peritoneal  space. 

"  Removal  of  an  impacted  pancreatic  calculus  In  the  duo- 
denal extremity  of  the  duct  of  WIrsung,  by  taxis  or  incision 
and  extraction,  should  be  practised  In  all  cases  where  the 
common  bile-duct  is  compressed  or  obstructed  by  the  calculus, 
and  death  is  threatened  by  chola?mia." 

*  Gaz.  des  hdpiiaux,  1856,  No.  2. 
41  * 


628  OPERATIONS  ON   THE  PANCREAS. 

As  yet,  these  indications  remain  to  be  fulfilled  by  the  surgery 
of  the  future.  Thus  far,  systematic  and  deliberate  surgical 
treatment  has  got  little  beyond  cysts  of  the  pancreas. 

The  origin  of  cysts  of  the  pancreas  is  not  fully  understood. 
As  a  rule  they  are  developed  in  the  tail,  very  rarely  in  the  head, 
of  the  gland.  They,  practically,  always  originate  from  retention 
of  the  pancreatic  secretion ;  but  obstruction  of  the  duct  is, 
according  to  Senn,  not  the  only  nor  the  most  important  element 
in  their  causation.  He  would  regard  as  the  most  important 
etiological  factor  "an  arrest  of  absorption  of  the  pancreatic 
juice,  due  either  to  a  transformation  of  the  pancreatic  juice  by 
the  admixture  of  pathological  products  into  the  substance  which 
is  capable  of  being  absorbed,  or  to  a  loss  of  function  in  this 
direction  of  the  vessels  which  perform  this  task,"  The  causes 
of  obstruction  are :  calculus ;  obliteration  of  a  portion  of  the 
duct,  by  cicatricial  contraction ;  and  displacement  of  the  pan- 
creas, with  flexure  of  the  duct,  caused  in  various  ways. 

The  size  of  the  cyst  varies  considerably.  The  cyst-walls 
are  usually  thin  in  rapidly-growing  tumours ;  and  thickened, 
cartilaginous,  or  even  calcified,  in  tumours  of  slow  growth. 
The  inner  surface  either  is  smooth,  or  it  presents  evidences  of 
degeneration  similar  to  those  which  occur  on  the  internal  sur- 
face of  arteries  in  the  later  stages  of  endarteritis.  In  cases 
where  the  duct  is  blocked  near  its  extremity,  the  duct  and  its 
branches  may  become  dilated,  presenting  the  appearance  of 
varicose  veins.  In  other  cases  the  cyst  is  globular.  The  gland 
tissue  is  destroyed  by  pressure  or  chronic  inflammation.  Pure 
pancreatic  juice  is  found  only  in  small  and  recent  cysts ;  later 
on,  in  old  or  large  cysts,  various  accidental  products  are  added. 
Sometimes  pus  and  blood  are  found. 

Diagnosis  is  possible  only  when  the  cyst  is  large,  and  then  it 
is  rarely  certain.  Cysts  of  the  pancreas  have  been  found  only 
in  adults.  A  history  of  painful  or  inflammatory  affection  in  the 
region  of  the  pancreas  is  to  be  looked  for.  Colicky  pains  in  the 
epigastrium,  often  of  great  violence,  are  sometimes  complained 
of.  This  symptom  has  been  called  coeliac  neuralgia,  and  is  said 
to  be  characteristic  of  pancreatic  cysts.     Frequently  the  cysts 


PANCREATIC  CYSTS.  629 

grow  with  great  rapidity.  Fatty  stools  point  towards  the  exist- 
ence of  some  co-existing  serious  lesion,  rather  than  to  simple 
cyst.  Digestion  is  often  impaired ;  and  frequently  there  is  emacia- 
tion, sometimes  to  a  very  marked  degree.  Undigested  muscular 
fibre  in  the  patient's  stools  is  suggestive  of  defective  pancreatic 
secretion.  A  peculiar  pale-yellow  or  earthy  colouration  of  the 
skin,  which  is  said  to  be  pathognomonic,  is  sometimes  observed. 
Diabetes  mellitus  is  occasionally  associated  with  pancreatic 
disease. 

The  cyst  makes  its  appearance  in  the  normal  situation  of 
the  pancreas ;  the  direction  in  which  it  increases  will  depend  on 
the  portion  of  the  pancreas  in  which  it  originated.  Thus,  its 
most  prominent  point  has  been  found  below  the  right  lobe  of  the 
liver,  in  the  epigastric  region,  and  in  the  left  hypochondrium. 
The  stomach  is  pushed  forwards  in  all  cases,  and,  later,  to  the 
right  side.  The  transverse  colon  is  displaced  downwards,  and 
the  spleen  to  the  left.  By  inflation  of  the  stomach  and  bowels 
and  thereby  making  out  its  position  behind  stomach  and  colon, 
Kocher,  in  a  patient  on  whom  he  operated,  was  able  to  diagnose 
cyst  of  the  pancreas.  The  tumour,  being  in  direct  contact  with 
the  diaphragm,  may  ascend  and  descend  with  the  respiratory 
movements.  Occasionally  the  tumour  vibrates  with  the  impulse 
of  the  abdominal  aorta,  on  which  it  rests.  Fluctuation  is  not 
always  perceptible  in  thick-walled  or  tense  cysts.  Exploratory 
puncture,  in  cases  where  diagnosis  is  imperative,  may  be 
employed.  In  a  case  of  pancreatic  cyst  reported  by  W.  T. 
Bull  of  New  York,*  fluid  withdrawn  by  a  h3^podermic  syringe 
was  found  to  be  dark-brown,  turbid,  odourless,  alkaline,  and  of 
specific  gravity  i.oio.  Chlorides  were  abundant ;  there  was  no 
bile,  and  only  a  trace  of  urea.  The  fluid  became  solid  on 
boiling.  The  microscope  revealed  degenerated  cells,  fat-globules, 
granular  matter,  and  haematin  crystals.  When  kept  at  a  tem- 
perature of  ioo°  Fall,  for  fifteen  minutes  with  some  boiled  rice, 
the  fluid  was  found  to  contain  one  grain  of  glucose  to  the  fluid 
draclim.  The  fluid  also  emulsified  oil.  In  this  case  also  free 
fat  was  found  in  the  faeces  and  sugar  in  the  urine,  to  the  extent 
often  grains  to  the  ounce. 

*  New  York  Med.  Journ.,  Oct.   ist,  1S87, 


630  OPERATIONS  ON  THE  PANCREAS. 

Cysts  of  the  pancreas  are  most  likely  to  be  confounded  with 
ovarian  cysts,  h3'dro-nephrosis,  circumscribed  peritonitis,  and 
hydatids  of  contiguous  organs.  In  at  least  three  cases,  pan- 
creatic cysts  have  been  taken  for  ovarian  cysts  by  eminent 
surgeons,  after  repeated  and  thorough  examination.  Of  about 
twenty  recorded  cases  of  operation,  correct  diagnosis  was  made 
in  only  six ;  namely,  in  those  of  Gussenbauer,  Senn,  Subotic, 
Bull,  Kocher  and  Kiister,-''  and  in  each  of  these  recovery  followed 
operation. 

THE     OPERATION. 

Tapping  or  aspiration  offers  little  prospect  of  success  as  a 
mode  of  treating  pancreatic  cysts :  the  fluid  would  almost 
certainly  re-accumulate.  Besides,  it  might  be  dangerous  as 
permitting  escape  of  the  cystic  fluid,  or  by  causing  injury  to 
omental  vessels. 

Extirpation  has  twice  been  attempted  :  once  by  Bozeman, f 
with  complete  success,  both  as  to  removal  of  the  tumour  and 
cure  of  the  patient;  and  once  by  Rokitansky,:|;  who  failed  to 
completely  remove  the  tumour,  and  lost  his  patient  from  septic 
peritonitis.  In  both  cases  operation  was  performed  for  sup- 
posed ovarian  disease :  Bozeman  recognised  the  true  nature  of 
the  cyst  during  operation ;  _  in  Rokitansky's  case  this  was  not 
done  till  after  death.  Extirpation  is  not  recommended  as  the 
operation  of  election.  If  the  growth  is  attached  near  the  tail  of 
the  pancreas,  and  has  a  marked  pedicle,  it  may  be  removed  with 
little  additional  risk  ;  but,  in  the  face  of  the  success  which  has 
attended  incision  and  drainage,  this  additional  risk  need  not  be 
incurred.  In  other  cases,  the  situation  of  the  tumour  at  the  head 
of  the  pancreas,  the  absence  of  a  pedicle,  and  the  existence  of  deep 
adhesions,  might  render  the  operation  very  difficult,  and  even  im- 
possible. If  the  cyst-wall  were  very  thin,  or  rotten  or  gangrenous, 
then  removal — partial  or  complete— might  be  attempted. 

Ogston  of  Aberdeen  j  operated  on  a  pancreatic  cyst  which 

*  Deutsche  mcd.  Woch.,  1887,  Nos.  10  and  11. 

t  Netci  York  Mcd.  Rec,  Jan.  14th,  1872.!      J   V/cin.  Mcd  Presse,  Nov.  15th,  1885. 

§  Personal  communication. 


OPERATION  FOR   CYST.  631 

was  adherent  to  the  front  of  the  abdomen,  ahiiost  bursting 
through  it,  by  elhptical  incision  around  the  adherent  portion 
into  the  peritoneum.  The  cyst  attachment  extended  over  both 
kidneys.  No  attempt  was  made  to  excise  the  growth ;  it  was 
emptied  of  pea-soup-looking  contents,  stitched  to  the  abdominal 
wall  all  around,  and  the  superfluity  of  cyst-wall  cut  off.  The 
patient  died  of  gangrene  of  the  cyst.  The  removal  of  super- 
fluous portions  of  the  cyst-walls,  if  they  are  very  thin  or 
unhealthy,  is  distinctly  advisable,  if  this  can  be  done  without 
causing  traction. 

The  best  treatment  is,  to  establish  a  pancreatic  fistula  by 
incising  the  cyst-wall,  and  suturing  the  opening  to  the  parietal 
wound. 

As  the  stomach  and  the  colon  lie  above  and  below  the  cyst, 
it  will  always  be  wise  to  commence  operation  with  these  viscera 
empty.  Except  in  Senn's  case,  and  in  Ogston's,  the  incision 
was  always  in  the  middle  line.  A  good  rule  is,  to  make  the 
incision  over  the  most  prominent  point  of  the  tumour.  This 
point  will  most  likely  overlie  the  seat  of  obstruction,  and  it  will 
be  the  situation  most  favourable  for  the  establishment  of  a 
fistula.  The  length  of  the  incision  need  not  exceed  two  inches, 
at  first  :  it  may  be  prolonged  if  necessary.  If  adhesions  exist 
between  cyst  and  omentum,  and  between  omentum  and  parietal 
peritoneum,  these  need  not  be  disturbed  ;  but  the  fluid  contents 
may  be  drawn  off  through  an  aspirating  trocar,  and  the  C3'st 
incised  and  stitched  to  the  parietes  afterwards.  If  there  are  no 
adhesions,  the  omentum  is  carefully  divided  over  the  c^-st,  all 
bleeding  points  being  ligatured ;  the  aspirating  trocar  is  in- 
serted ;  and,  as  soon  as  relief  of  tension  permits  of  it,  two  catch- 
forceps  are  made  to  grasp  the  cyst-wall  and  pull  it  forward. 
When  the  cyst  is  empty,  and  as  far  as  possible  pulled  through 
the  wound,  the  opening  made  by  the  trocar  is  enlarged  by 
scissors  sufficiently  to  admit  of  the  introduction  of  a  large 
drainage-tube,  and  sutured  with  the  parietal  peritoneum  to  the 
skin. 

Senn  recommends  an  operation  in  two  stages  by  packing  the 
bottom  of  the  wound  over  the  cyst-wall  with  iodoform  gauze, 


632  OPERATIONS   ON   THE   PANCREAS. 

and  opening  the  cyst  after  six  or  eight  days.  Probably  the 
most  recent  experience  of  direct  incision  and  drainage,  in  the 
treatment  of  distension  of  the  gall-bladder  and  allied  conditions, 
would  cause  him  to  modify  this  suggestion. 

Discharge  of  pancreatic  secretion  will  probably  be  abundant, 
requiring  the  use  of  some  local  application,  such  as  carbolised 
oil,  to  prevent  it  from  acting  on  the  skin.  The  drainage-tube 
is  shortened,  and  changed  for  one  of  smaller  calibre,  as  the  depth 
of  the  cavity  diminishes,  and  the  amount  of  discharge  decreases. 

With  the  obliteration  of  the  C3St-cavity  we  may,  in  some  cases 
at  least,  expect  restoration  of  the  continuity  of  the  pancreatic 
duct.  A  calculus  should  be  looked  for,  and,  if  possible,  removed. 

Appreciation  and  Mortality. — Senn  reports  cases  of  pancreatic 
C3'St  healed  by  incision  and  drainage  at  the  hands  of  the  follow- 
ing surgeons:  Senn,*  Kulenkampft, f  Gussenbauer,]:  and  Hahn,§ 
— all  of  them  successful.  Ogston's  case  was  more  than  simple 
incision  and  drainage.  A  successful  operation  has  been  re- 
corded by  Bull  of  New  York,||  and  another  has  been  reported 
by  Witzel,*:  from  the  Bonn  Clinic.  Treiberg  has  collected 
some  ten  more  cases. 

In  the  following  cases  removal  was  either  attempted  or 
carried  out:  Bozeman  —  case  already  described  —  recovery: 
Rokitansky  —  case  described  —  incomplete  removal,  death: 
Luecke,*"'''  tapping,  subsequent  laparotomy,  closure  of  abdo- 
minal wound,  death  ;  malignancy  found  post-mortem  :  Riedel,tt 
separation  of  adhesions,  haemorrhage,  ligature  en  masse,  death 
from  peritonitis:  Billroth,]!  difficult  enucleation,  ligation  of 
large  vessel,  death  from  peritonitis.  According  to  Treiberg, 
extirpation  was  attempted  by  Zukowsky,  Riedel,  Saleer,  and 
Koote.     All  died  except  Bozeman's  case. 

The  evidence  thus  far  is  strongly  in  favour  of  simple  incision 
and  drainage,  leaving  the  attachments  undisturbed. 

*  Amer.  Joimi.  Med.  Sc,  July,  1885.      t  Berlin  Klin.  Woch.,  Feb.  13th,  1882. 

\  Archil'./  Klin.  Chir.,  vol.  xxix.,  p.  355.         §  Centralbl.f.  Chir.,  No.  2,  1885. 

ll  Loc.  cit.         ir  Deutsche  Zeit.f.  Chir.,  XXX.,  iii.,  Aug.  25th,  1886. 

**  Wvchow' s  Archiv.,  xli.,  p.  9.  ft  Archiv,  f.  Klin.  Chir.,  xxxii.,  p.  994. 

\\  Reported  by  Salzer  from  Biilroth's  Clinic. 


Section    XII 


UNCLASSIFIED  OPERATIONS  FOR   GROWTHS  IN 

OMENTUM,  MESENTERY,  PERITONEUM, 

AND  PARIETES. 


A  CERTAIN  number  of  comparatively  rare  tumours,  not 
connected  with  special  organs,  but  amenable  to  surgical 
treatment,  remain  for  consideration.  Such  tumours  are 
mainly  extra-peritoneal,  arising  in  the  sub-peritoneal  cellu- 
lar tissue,  or  in  rudimentary  or  obsolete  structures  in  that 
tissue,  or  in  the  parietes.  They  are  rarely  diagnosed  with 
accuracy,  and  their  removal  must  be  carried  out  without 
premeditation,  and  on  such  general  principles  as  the  surgeon 
has  mastered. 

Tumours  in  the  Omentum. 

Cysts  of  the   Omentum,  not   hydatid,  are  of  very  rare  occur- 
rence.    A  good  few  examples,  in  which  the  tumours  have  been 
removed,  are  however  recorded.    Thornton^'  relates  the  removal 
*  Brit.  Med.  Jonrn.,  ii.,  1882,  p.  1243. 


<334  OMENTAL   TUMOURS. 

of  two  small  omental  C3'sts  during  the  performance  of  ovari- 
otomy. One  was  a  small  multilocular  cystic  tumour,  of  the  size 
of  a  black  Kentish  cherr}^,  which  was  found  to  be  attached  by  a 
small  pedicle  in  the  lower  border  of  the  omentum.  The  patient 
hiad  papillomatous  cystic  disease  in  both  ovaries;  and  this  small 
tumour,  a  perfect  multilocular  ovarian  tumour  in  miniature, 
Thornton  considers,  owed  its  origin  to  cell-infection.  The 
second  was  a  tumour,  of  the  size  of  a  small  cocoa-nut,  with  a 
very  thick  white  fleshy  wall  and  a  small  central  cavity,  which 
had  a  puckered  lining  membrane  and  contained  three  or  four 
ounces  of  thick  yellowish  fluid.  The  tumour  was  attached  by  a 
thick  vascular  pedicle,  and  lay  high  up  in  the  abdomen  under 
the  right  border  of  the  liver,  and  was  nearly  overlooked  during 
the  removal  of  a  large  cysto-sarcoma  of  the  ovary.  This 
tumour  also  Thornton  considers  to  have  originated  from  cell- 
infection. 

Doran-''  relates  an  interesting  example  of  ovarian  cyst. 
Dr.  Gooding,!  of  Cheltenham,  successfully  removed  a  large  cyst, 
containing  clear  fluid,  from  between  the  folds  of  the  omentum. 
The  tumour  had  been  growing  for  four  years,  had  caused 
latterly  somewhat  troublesome  symptoms,  and  when  removed 
was  about  the  size  of  a  child's  head.  The  cyst  was  enucleated 
after  a  tedious  process  of  separation  ;  there  was  no  pedicle,  the 
growth  being  embedded  in  the  folds  of  the  omentum,  and 
having  the  transverse  colon  below  it.  The  tumour  was  not 
hydatid ;  and  Dr.  Gooding  considers  that  its  origin  might  have 
been  due  to  a  severe  blow  in  the  abdomen,  sustained  some 
months  before. 

Dr.  Buckley,  [  of  Manchester,  has  removed  a  cholesterine 
cyst  of  the  omentum,  weighing  32  ounces.  The  cyst  was 
thick-walled  and  globular,  and  its  contents  were  cholesterine, 
fat,  and  compound  granular  debris, —  the  whole  soluble  in 
ether. 

Ormsby  j  removed  successfully,  from  a  woman  of  26,  a 
multilocular  cystic  growth,  attached  by  a  well-defined  pedicle  to 

*  Obstet.  Trans.,  xxiii.,  p.  165.         t  Lancet,  Feb.  12th,  1SS7. 
\  Brit.  Med.  Joiiyn.,  May  i6th,  1885.       §  Brit.  Med.  Jouni.,  i.,  1883,  p.  578. 


HYDATIDS   OF  OMENTUM.  635 

the  omentum,  weighing  75  pounds.  The  nature  of  the  growth 
is  not  described  in  the  short  notice  of  the  operation. 

Last  year  I  removed  a  C3'Stic  tumour,  attached  only  to  the 
omentum,  from  a  married  woman  aged  44.  It  consisted  of  one 
large  cyst,  containing  nine  pints  of  clear  albuminous  fluid,  in  a  sac 
of  uniform  thickness  and  of  pearly-white  colour.  At  the  site  of 
its  attachment  to  the  omentum  were  several  semi-solid  masses, 
together  about  as  large  as  the  closed  fist.  Sections  through 
these  disclosed,  in  one  portion,  a  cavity  containing  characteristic 
dermoid  material,  with  hairs  and  cartilaginous  nodules ;  in 
another  part,  an  aggregation  of  minute  cysts,  full  of  clear  bright- 
3'ellow  fluid  which  floated  in  globules  on  water,  and  was  evidently 
liquid  fat.  In  the  largest  of  these  cysts  small  coherent  masses 
of  pure  fat  were  found.  The  pedicle  was  simple  omentum, 
about  as  thick  as  two  fingers.  Near  the  insertion  of  the  pedicle 
was  a  fleshy  mass,  which  was  the  enlarged  fimbriated  extremity 
of  a  Fallopian  tube.  Not  till  the  growth  was  examined,  after 
the  operation  was  concluded,  did  I  suspect  that  the  cyst  was 
really  ovarian,  the  pedicle  having  been  twisted  through.  A 
thorough  examination  of  the  tumour  by  Mr.  Bland  Sutton''' 
showed  it  to  be  a  mixed  dermoid  and  glandular  ovarian  growth. 

Hydatid  Cysts  of  the  Omentum  have  several  times  been  re- 
moved. Solitary  echinococcus  cysts  of  the  omentum  are  rare. 
Wickham  Legg,!  Annandale,  Witzel,  and  others  have  described 
cases.  Witzel,!  in  relating  a  case  of  omental  hydatid  occurring 
in  a  girl  of  ten  on  whom  he  operated,  takes  occasion  to  fully 
discuss  the  symptoms  and  treatment.  Pain,  lateral  and  upward 
mobility,  movements  synchronous  with  the  respiratory  acts,  and 
certain  digestive  disorders,  are,  in  addition  to  the  physical  signs, 
the  leading  features  of  the  disease.  As  to  treatment,  he  recom- 
mends, if  there  are  adhesions,  incision  and  drainage.  If  there 
are  numerous  hydatids  in  the  lower  portion  of  the  omentum,  he 
recommends  removal  of  the  omentum,  after  the  application  of  a 
number  of  ligatures  above  the  growth.  Solitary  echinococcus 
should  be  treated  by  incision,  after  fixation  to  the  parietal  wound 

*  By  it.  Gynac.  Joiirn.,  Nov.,  1887.         f  Trans.  l\ith.  Soc,  xxv. ,  p.  iCo. 
\  Deutsche  Zciisclir.  f.  CJiir.,  1S83. 


636  MESENTERIC    TUMOURS. 

with  sutures,  and  drained.  A  small  echinococcus  cyst  might 
be  shelled  out  of  its  bed  in  the  omentum  without  being 
opened. 

Abscess  occurring  in  an  omental  sac  is  of  the  nature  of  a 
localised  suppurative  peritonitis,  and  its  treatment  is  identical. 

Sanguineous  Tuniours  of  the  omentum  are  very  rarely  met  with. 
Dr.  Reamy,  of  Cincinnati, "^^  relates  three  cases  of  semi-fluctu- 
ating growths  of  the  omentum,  which  yielded  pure  blood  on 
being  tapped.  These  were  sarcomata,  as  indeed  are  probablj' 
all  such  growths.  Doran,  Thornton,  Gardner,  and  others  have 
related  similar  cases.  Bristowe  f  relates  a  case  in  which  cure 
followed  several  evacuations  of  pure  blood  by  tapping,  and 
which  might  have  been  an  omental  cyst ;  but  was,  in  Bristowe's 
opinion,  more  probably  either  a  hsemato-nephrosis,  or  a  cyst  of 
the  spleen. 

Malignant  disease  of  the  omentum,  either  local  or  as  a  part 
of  general  peritoneal  cancer,  requires  no  description. 


Tumours  in  the  Mesentery. 

A  considerable  number  of  operations  for  mesenteric  cysts 
and  tumours  have  been  recorded. 

Sir  Spencer  Wells  |  has  operated  on  two  occasions  for  mesen- 
teric growths,  one  being  cystic  and  the  other  solid.  He  incised 
and  drained  the  cyst :  the  patient  died  after  a  few  weeks ;  and 
as  no  further  examination  was  permitted,  the  exact  nature  of 
the  disease  was  not  ascertained.  The  solid  growth,  which  was 
about  the  size  of  a  child's  head,  was  successfully  removed  by 
enucleation.  Its  origin  was  in  the  cellular  tissue  at  the  root  of 
the  mesentery  proper,  near  the  lumbar  vertebrae.  The  ascend- 
ing colon  was  closely  connected  with  the  tumour,  in  front  and 
to  the  right  ;  and  all  its  blood-supply  was  derived  from  the 
mesenteric  vessels.  The  exact  nature  of  the  growth  is  not 
recorded. 

*  Trans.  Am.  Gyn.  Soc,  viii.,  1883,  p.  123.       f  Lancet,  May  5th,  1883. 
\  Brit.  Med.  Jouvn.,  Dec.  gth,  1882. 


LIPOMA    OF  THE   MESENTERY.  637 

Lipoma  of  the  mesentery  has  been  met  with,  and  removed. 
Terrillon*  recently  presented  to  the  Academy  of  Medicine  of 
Paris  a  patient  from  whom  he  had  removed  a  fatty  tumour, 
weighing  fifty-seven  pounds,  by  enucleation  from  between  the 
layers  of  the  mesentery, 

Homansf  of  Boston  has  recorded  two  cases  of  removal  of 
enormous  fatty  tumours  from  the  abdomen,  which  were  retro- 
peritoneal, and  may  have  been  originally  mesenteric.  In  fact, 
mesenteric  tumours  might  properly  be  classified  under  the  more 
comprehensive  designation  of  retro-peritoneal.  Homans's  first 
case  was  that  of  a  man  aged  thirty-nine.  The  girth  at  the 
umbilicus  was  42I  inches ;  and  the  tumour  felt  so  fluctuating 
in  parts,  that  it  was  punctured  several  times  in  the  expec- 
tation of  finding  fluid.  A  first  attempt  to  remove  it  failed, 
and  a  second  and  successful  attempt  was  made  some  months 
later.  The  operation  was  one  long  and  tedious  process  of 
enucleation  from  behind  the  peritoneum  and  bowels.  The 
patient  sank  from  shock.  His  second  case,  in  a  woman  of 
sixty,  was  very  similar  to  the  first :  this  patient  also  died  of 
shock. 

Cooper  Forster  showed  at  the  Pathological  Society,  in  1868, 
an  enormous  fatty  tumour,  removed  after  death  from  a  woman, 
which  had  features  in  common  with  those  described  by  Homans. 
Three  other  cases  are  described  in  the  Pathological  Society's 
Transactions.  A  similar  case  is  said  by  Homans  to  have  occurred 
in  the  practice  of  Professor  Calvin  Ellis,  of  Harford  University. 

Cysts  of  the  Mesentery  have  attained  to  dimensions  so  consider- 
able, that  they  have  been  mistaken  for  ovarian  tumours,  Pean  X 
described  three  such  operations,  with  one  success.  Watts  j 
relates  another  case  of  operation  for  mesenteric  C3'st  mistaken 
for  ovarian  cystoma.  Carter  [|  operated  on  a  cyst  which  sprang 
from  the  left  side  of  the  spine  in  the  lumbar  region  where  the 
mesentery  is  attached,  and  arose  either  between  its  folds  or 
from  the  sub-peritoneal  tissue  below   it.      It   contained  about 

*  Letter  in  Journ.  Amcr.  Med.  Assoc.        +  Lancet,  i.,  1883,  p.  449. 

I  Tumcurs  dc  VAbdomen.  %  Amcr.  Journ.  Obstct.,  1879,  xii.,  p.  333. 

II  Brit.  Med.  Journ.,  Jan.  6th,  1883. 


638  MESENTERIC   TUMOURS. 

sixteen  pints  of  a  thin,  clear,  slightly  opalescent  fluid,  free  from 
albumen,  and  containing  a  large  amount  of  chlorides — in  fact, 
presenting  characters  identical  with  the  fluid  found  in  h3'datid 
cysts.  No  hooklets  or  other  structures  characteristic  of  echino- 
coccus  were  found.  The  patient  was  a  married  woman,  aged 
44.  There  was  a  history  of  two  years'  growth  of  the  tumour, 
with  some  pain.  On  opening  the  peritoneum,  the  tumour 
appeared  as  a  thin-walled  cj-st,  covered  in  all  directions  with 
large  veins.  It  was  tapped,  and  found  to  be  attached  to  the 
side  of  the  spine  and  the  left  lumbar  region,  while  it  was  closely 
surrounded  by  coils  of  small  intestine  which  were  firmly  adherent 
to  it.  An  attempt  was  made  to  enucleate  it ;  but  haemorrhage 
was  so  free  that  the  operator  had  to  desist,  and  finished  by 
stitching  the  cyst- wall  to  the  parietal  opening,  cutting  away  as 
much  of  it  as  possible,  and  draining  the  cavity.  The  patient 
died  of  septicaemia  and  bleeding. 

I  know  of  two  other  cases,  not  yet  published,  of  mesenteric 
growths  removed  b}'  operation. 


Extra-peritoneal  Cysts. 

Extra -peritoneal  cysts  underlying  the  anterior  abdominal 
\vall  form  an  exceedingl)^  interesting  class.  In  most  of  them  a 
connection  with  the  urachus  has  either  been  demonstrated  or 
rendered  highly  probable.  An  exceedingly  valuable  report  of 
twelve  such  cases,  operated  upon  b}^  Lawson  Tait,'''  has  recently 
been  published.  Of  the  12  operations,  4  died,  and  8  recovered. 
The  origin  of  all  of  them  he  is  inclined  to  ascribe  to  a  patholo- 
gical process  in  some  way  connected  with  an  arrested  or  imper- 
fect closure  of  the  urachus.  In  three  of  the  cases  there  was 
found  to  exist  a  connection  between  the  bladder  and  the  cyst. 

In  his  first  case,  the  C5'st-wall  appeared  after  division  of  all 
the  layers  except  the  peritoneum.  Thirty  pints  of  brown  thick 
fluid,  with  an  abundant  flaky  yellow  deposit  consisting  chiefly  of 
*  Brit.  Gynae.  Soc.  Journ.  Nov.  Gth,   18S8. 


EXTRA-PERITONEAL   CYSTS.  639 

pus  and  mixed  with  large  fibrinous  masses,  were  removed  by 
tapping.  The  cyst -wall  was  completely  enucleated  without 
entering  the  peritoneum.  "  The  cyst  did  not  dip  into  the  pelvis 
at  all,  and  the  anterior  parietal  peritoneum  did  not  reach  the 
wall  lower  than  the  ensifprm  cartilage.  The  intestines  and  the 
pelvic  organs  could  be  felt  through  the  anterior  peritoneal  fold, 
non- adherent,  and,  as  far  as  could  be  determined,  perfectl}^ 
health}'."  The  inner  surface  of  the  "  cyst  consisted  of  broken- 
down  mucoid  epithelium,  infiltrated  everywhere  with  pus  l3'ing 
upon  tiie  basement  membrane,  which  consisted  almost  entirely  of 
muscular  fibres."    The  patient  died,  in  three  days,  of  exhaustion. 

In  the  second  case  several  pints  of  putrid  urine  were  evacu- 
ated from  the  C3-st,  and  the  patient  recovered  with  a  urinary 
fistula.  She  died,  a  month  later,  of  the  effects  of  a  miscarriage. 
In  the  third  case,  the  patient  was  in  an  almost  helpless  condition, 
from  suppuration  in  the  cyst  and  gangrene  of  its  walls,  and  died 
of  exhaustion  from  excessive  suppuration  seventeen  days  after 
operation.  The  condition  in  this  case  was  ver}'  similar  to  that 
found  in  the  first. 

In  the  fourth  case,  the  peritoneum  covering  the  cyst  left  the 
abdominal  wall  about  two  and  a  half  inches  above  the  umbilicus, 
and  "presented  a  curvilinear  fold  running  down  outwards  and 
backwards  symmetrically  on  each  side  to  about  the  middle  of 
the  great  crest  of  the  ilium,  and  this  was  reflected  at  once  on  to 
the  promontory  of  the  sacrum.  Behind  this  apron,  consisting 
of  the  cyst-wall  and  peritoneum  united,  the  intestines  and  other 
organs  could  be  felt.  The  whole  of  the  pelvis  was  entirel}' 
destitute  of  peritoneum,  and  was  occupied  instead  by  a  cyst- 
wall  ;  and  standing  up  in  the  middle  of  the  cavity,  bounded  on 
both  sides  by  the  C5'st-wall,  was  the  uterus,  and  what  ought  to 
have  been  the  broad  ligaments.  Tlie  bladder  had  a  similar 
relation  to  the  cyst-wall  that  it  ought  to  have  had  to  the  peri- 
toneum ;  and  then  from  the  base  of  the  bladder,  running  up  and 
lining  the  posterior  surface  of  the  transversalis  fascia,  was  the 
continuation  of  the  cyst-wall.  The  fluid  of  the  cyst  was  clear, 
and  floating  in  it  were  shreds  of  delicate  membrane,  with  lumps 
of  fat  in  it,  presenting  precisely  the  appearance  of  the  omentum 


640  EXTRA-PERITONEAL  CYSTS. 

of  the  foetus."  The  C3'st  was  emptied,  sponged  out,  and  drained. 
Suppuration  set  in,  and  killed  the  patient  six  weeks  after 
operation. 

The  fifth,  sixth,  seventh,  eighth,  and  ninth  cases  were  very 
similar  to  the  fourth.  The  tenth  case  had  been  previously 
operated  upon  by  another  surgeon.  The  cyst-walls  "were  of 
that  peculiarly  gelatinous  friable  material  which  is  common  to 
all  these  cases."  After  dissecting  through  the  posterior  wall  of 
the  cyst,  the  operator  found  immediately  underneath  it  the  loose 
vascular  serous  tissue  observed  in  some  of  the  other  cases- 
Dissecting  carefully  on,  he  came  upon  a  piece  of  intestine,  and 
then  with  his  fingers  found  that  he  "could  readily  separate  the 
coils,  which  were  attached  to  it,  not  by  adhesions,  but  by 
connective  tissue,  very  extensile  and  what  we  are  perfectly 
accustomed  to  in  all  regions  which  are  immediately  connected 
with  organs  not  enveloped  in  the  peritoneal  layers,  the  appear- 
ances being  totally  different  from  those  of  inflammatory 
adhesions.  The  cyst  travelled'  everywhere  down  into  the  pelvis, 
and  the  pelvic  organs  could  be  felt  through  its  walls."  It 
seemed  to  the  operator  that  this  patient  had  no  peritoneal 
cavity  at  all,  and  that  the  intestines  lay  enveloped  in  fat  and 
loose  extensile   cellular  tissue. 

Cases  xi.  and  xii.  were  not  unlike  the  others.  Portions  of 
the  cyst-wall  of  case  xi.  were  removed,  and  submitted  to  micro- 
scopic examination  by  Mr.  Bland  Sutton.  He  found  a  "mix- 
ture of  fibrous  and  non- striated  muscle -tissue,  arranged  in 
fasciculi  closely  corresponding  to  the  disposition  of  the  bundles 
of  tissue  which  make  up  the  walls  of  the  urinary  bladder. 
Scattered  throughout  the  whole  thickness  of  the  sections  were 
small  calcareous  nodules.  It  was  difficult  to  make  out  any  defi- 
nite epithelial  investment  to  the  sections ;  but  on  scraping  the 
smooth  surface  of  the  specimen  with  a  cover  glass,  the  field  of 
the  microscope  became  crowded  with  flattened,  rounded,  and 
pyriform  cells,  similar  to  those  found  lining  the  interior  of  the 
urinary  bladder,  only  very  much  smaller."  Mr.  Sutton  con- 
siders that  "as  the  urachus  is  lined  with  epithelium  agreeing 
in  shape,  and  continuous  with  that    found    in    the    interior    of 


EXTRA-PERITONEAL  CYSTS.  641 

the   bladder,"   the   evidence   in   favour   of    these    cysts    being 
allantoic    is    complete."' 

Bantockf  relates  two  cases,  very  similar  to  those  of  Tait. 

Certain  cases  of  retro-peritoneal  cysts  containing  chylous 
contents  have  been  recorded. ;[:  These  are  probably  connected 
with  the  thoracic  duct  or  other  large  lymph-channels.  The 
treatment  is  incision  and  drainage. 

Tumours  not  cystic  are  found  in  connection  with  the  ura- 
chus — sarcoma,  for  instance.  Mr.  Ewens  recently  exhibited  at 
the  Bristol  Medico- Chirurgical  Society  a  remarkable  specimen 
of  sarcoma  of  the  urachus  which  he  had  attempted  to  remove. 
Such  cases  have,  however,  a  pathological  rather  than  a  prac- 
tical interest. 

New  growths  in  the  parietes,  originating  in  the  muscles  or 
fasciae,  though  they  bulge  inwards  on  the  peritoneal  cavity  and 
may  require  removal  of  peritoneum  before  they  can  be  com- 
pletely eradicated,  do  not  require  special  description.  Weir§ 
has  operated  successfully  on  one  of  the  most  remarkable  cases  of 
this  sort :  the  tumour  weighed  nearly  fourteen  pounds.'  Briddon, 
Thomas,  Heineke,  Czerny  and  others  have  had  similar  cases. 
Sarcoma  is  the  form  of  new  growth  most  frequently  met  with  in 
the  parietes.  Around  or  in  the  umbilicus  are  found  polypus, 
papilloma,  fibroma,  and  epithelioma.  I  have  seen  a  case  of 
epithelioma  of  the  umbilicus  complicated  with  intestinal  fistula. 

For  all  such  rare  and  peculiar  conditions,  definite  and  pre- 
cise rules  for  operative  treatment  cannot  be  laid  down.  Most 
cases  come  upon  the  surgeon  as  a  surprise ;  and  their  operative 
handling  must  be  decided  upon  on  the  spur  of  the  moment,  and 
carried  out  according  to  broad  principles  established  for  ab- 
dominal operations  in  general. 

*  For  further  information  concerning  Allantoic  cysts,  consult  Bland 
Sutton's  Introduction  to  General  Pathologv,  where  also  further  references  may 
be  found.  An  exhaustive  paper  on  Abnormalities  of  the  Urachus,  by  James  A, 
Freer  of  Washington,  is  published  in  the  Annals  of  Surgery  for  Feb.,  1887. 

t  Brit.  Gycec.  Soc.  Joimi.,  Nov.,  1886,  p.  348. 
J  Kilian.  Berlin.  Klin.  IVoch.,  xxv.,  18S6.        §  N.Y.  Med.  Rec,  Dec.  3rd,  1887. 

42 


Section  XIII. 


SUPRA-PUBIC     CYSTOTOMY. 


I  HAVE  adopted  this  name  for  the  operation  to  be  described 
because  it  is  the  one  generally  used.  Epicystotomy  is  not 
definite  enough :  it  might  be  applied  to  the  gall-bladder  as  well 
as  to  the  urinary  bladder.  Hypogastric  cystotomy  is  the 
name  I  prefer :  it  is  sanctioned  by  historic  usage  (cystitomia 
hypogastrica) ;  it  is  the  name  most  commonly  used  in  France 
(taille  hypogastrique) ;  and,  as  naming  the  operation  from  the 
region  in  which  it  is  performed,  it  runs  parallel  with  a  similar 
operation  performed  in  another  region — the  perineum.  But 
there  is  no  strong  objection  to  the  term  adopted,  and,  as  I  have 
said,  it  is  the  one  best  known.  The  "High  Operation"  (Sectio 
alta)  is  a  name  frequently  employed. 


HISTORY.  643 


HISTORY. 

In  this,  as  in  other  historical  enquiries,  we  have  to  discrimi- 
nate between  the  man  who  ignorantly  stumbled  on  the  invention, 
and  him  who  knowingly  elaborated  it ;  a  third  individual,  who 
follows,  imitates,  modifies,  or  perverts,  also  requires  con- 
sideration. 

It  is  a  curious  fact  that  Pierre  Franco  (or  de  Franco,  as  he 
is  sometimes  named),  the  surgeon  who  first  performed  the 
operation,  deserves  no  credit  as  its  inventor;  while  its  real 
inventor,  Roussetus,  never  performed  it.  Franco  was  a  surgeon 
who  practised  at  Tourrieres,  in  Provence,  and  at  Lausanne, 
during  the  middle  and  latter  portion  of  the  sixteenth  century. 
In  1556  (not  1561 — a  later  edition — or  1581,  as  is  sometimes 
stated)  he  published  at  Lyons  a  book  on  Hernia.'''  A  re- 
impression  of  this  first  edition  was  printed  during  1884  in  the 
Revue  de  Chivurgie.  In  the  course  of  his  narrative  he  makes  the 
following  "reciteray:"  "I  will  recite  what  once  happened  to 
me,  intending  to  extract  a  stone  from  a  child  of  two  years  old, 
or  thereabout ;  in  which,  having  found  the  stone,  of  the  bigness 
of  a  hen's  egg,  or  very  near,  I  did  all  I  could  to  bring  it  down 
[on  the  gripe] ,  and  finding  that  I  was  not  able  to  bring  it 
forward  by  all  my  endeavours,  the  patient  being  exceedingly 
tormented,  and  also  the  parents  desiring  that  he  should  die 
rather  than  live  in  such  misery ;  add  to  this,  that  I  was  not 
willing  to  be  reproached  with  not  being  able  to  extract  it 
(which  was  great  folly  in  me),  I  determined,  with  the  impor- 
tunity of  the  father,  mother,  and  friends,  to  cut  the  said  child 
above  the  os  pubis,  since  the  stone  could  not  fall  down  ;  and  he 
was  cut  above  the  pubis,  a  little  on  one  side  (un  peti  a  coste),  upon 
the  stone ;  for  I  lifted  it  up  with  my  fingers,  which  were  in  the 
anus,  and  on  the  other  side  holding  it  down,  by  the  hands  of  a 
servant,  which  pressed  the  belly  upon  the  stone,  by  which 
means  the  stone  was  extracted,  and  a  little  after  the  patient 
was  cured  (notwithstanding  he  had  been  very  ill),  and  the 
*  Petit  Traitd  suy  Us  Hcrnies. 
42  * 


644  SUPRA-PUBIC  CYSTOTOMY. 

wound  healed.  However,  I  do  not  advise  anj^  man  to  do  the  like." 
This  is  Cheselden's  very  correct  translation  of  Franco's  words. ^' 
In  1590  Roussetus  published  his  great  work  on  Caesarean 
Section,  in  which  he  gave  a  minute  and  accurate  account  of  the 
anatomy  of  the  parts  concerned.  Roussetus  was  the  greatest 
physician  of  his  day,  possessed  of  an  insight  and  knowledge 
which  came  very  near  to  being  genius.  It  is  not  surprising, 
therefore,  that  his  studies  in  the  anatomy  of  Cesarean  Section 
suggested  the  hypogastric  route  for  entering  the  bladder.  Rous- 
setus kneAv  of  Franco's  operation,  and  sharply  censured  him  for 
dissuading  others  from  following  in  his  footsteps,  while  he 
sensibly  combats  the  generally  received  opinion  that  wounds 
of  the  bladder  were  necessarily  fatal.  Finally,  he  elaborated  the 
operation  which  he  recommended  by  experimenting  on  the  dead 
bod}' ;  and  this  operation  is,  to  all  intents  and  purposes,  the 
operation  as  it  is  performed  to-day.  The  patient  is  laid  on  his 
back,  the  bladder  is  filled  with  milk,  or  barley-water,  or  a 
"  vulnerary  decoction,"  by  means  of  a  syringe  which  fits  on  to  a 
silver  catheter  ;  the  penis  is  grasped  by  the  hand  of  an  assistant, 
or  tied  by  a  "  soft  twist  of  cotton."  He  then  accurately 
describes  the  supra-pubic  incision,  and  the  mode  of  exposing 
the  bladder.     The  puncture  in  the  bladder  is  made  by  a  sharp- 

*  I  give  Franco's  own  words  because,  in  the  only  recent  English  monograph  on 
the  operation  (Sir  Henry  Thompson's),  the  method  Franco  employed  is  said  to 
have  been  "  to  inject  the  bladder  forcibly  with  water,  the  presence  of  which 
was  insured  by  the  assistant  grasping  the  penis  during  the  operation,  and  to 
dissect  the  bladder  in  the  median  line  without  a  staff,  opening  the  organ  at 
the  anterior  aspect  behind  the  symphysis."  Franco  distinctly  says  he  did  not 
cut  in  the  median  line,  and  his  simple  words  can  scarcely  be  elaborated  into 
describing  injection  of  the  bladder  and  grasping  the  penis.  Thompson's 
historical  remarks  are  in  other  respects  open  to  criticism.  Thus,  he  confuses 
John  Douglas,  the  surgeon  who  first  operated,  with  his  brother,  James 
Douglas,  the  physician  who  first  publicly  brought  forward  the  operation.  The 
sentence  (p.  9) :  "About  this  time  several  provincial  surgeons  pubHshed  cases 
of  the  high  operation,  such  as  Pye  and  Thornhill  of  Bristol,  Middleton,  and 
Macgill  of  Edinburgh,  1722-24,"  contains  several  errors.  Middleton  was 
not  of  Edinburgh,  but  of  Bristol,  and  he  was  not  a  surgeon,  but  a  pure 
physician  of  the  old-fashioned  type,  who  probably  never  performed  an  opera- 
tion in  his  life.  It  happened  that  he  wrote  for  his  friend  and  colleague, 
Thornhill  the  surgeon,  the  work  to  be  presently  described.  A  copy  of  this 
work  (annotated  apparently  by  the  author)  is  now  before  me,  and  is  dated  1727. 


HISTORY.  645 

pointed,  sickle-shaped  knife  ;  through  this  puncture  a  curved, 
probe-pointed  knife,  blunt  at  the  point,  so  as  to  pull  the  bladder 
upwards  while  it  did  not  cut  it,  is  insinuated  to  enlarge  the 
incision.  An  assistant  pushes  the  stone  forwards  with  his 
finger  in  the  anus  in  men,  and  in  the  vagina  in  women,  and 
the  surgeon  extracts  the  stone  by  fingers,  forceps,  or  scoop,  as 
seems  most  convenient.  An  alternative  method,  to  meet  cer- 
tain cases  of  difficult)',  is  to  use  a  greatly  curved  and  furrowed 
sound,  on  the  point  of  which  the  incision  into  the  bladder  may 
be  made.  He  thus  anticipates  certain  subsequent  procedures. 
Gradual  distension  of  the  bladder  by  ligating  the  penis  and 
preventing  the  discharge  of  urine,  he  speaks  somewhat  dubiously 
about.     It  is  physiologically  sound,  but  practically  intolerable. 

Hildanus  (1682)  and  Dionis  (1714)  finding  it  necessary  to 
introduce  a  description  of  the  operation  into  their  works,  did  so, 
but  without  discrimination  or  even  accuracy.  Bonnet,  a  surgeon 
to  the  Hotel  Dieu,  previous  to  this  time,  is  said,  chiefly  on  the 
authority  of  Tolet,  to  have  operated  b}'  the  high  method  ;  but 
he  has  left  no  literary  proof  to  this  effect.  Simon  Pietre,  a  Paris 
physician,  wrote  a  short  treatise  in  favour  of  the  operation  in 
1635 ;  and  various  references  in  general  works  subsequent  to 
this  time  would  seem  to  show  that  the  subject  was  simmering  in 
the  minds  of  surgeons  in  Paris.  At  length  Francis  Collet  was 
authorised  to  make  experiments  and  report  to  the  faculty  at 
Paris ;  he  reported  unfavourably,  and  the  operation  was  pro- 
hibited. Elsewhere  a  few  stray  operations  were  performed, 
rather  from  necessity  than  choice.  Thus,  Groenvelt,  a  Dutch 
surgeon,  who  wrote  a  treatise  on  Lithotomy,  in  English,  in  1710, 
relates  how  he  was  once  driven  to  perform  the  operation. 
Proby,  a  Dublin  surgeon,  published  in  the  Philosophical  Trans- 
actions, in  1700,  an  account  of  a  case  in  a  woman  where,  having 
failed  to  remove  a  long  pin  through  the  urethra,  he  cut  down  on  the 
point,  which  was  made  to  bulge  over  the  pubes,  and  removed  it  in 
this  way.  These  and  similar  operations  had  no  influence  on  the  ad- 
vancement of  the  operation,  and  it  may  be  said  steadily  to  have 
declined  in  favour  till  171 8,  when  the  brothers  Douglas  took  it  up. 

On  January  23rd,  1718,  Dr.  James  Douglas  read  a  paper  on 


646  SUPRA-PUBIC  CYSTOTOMY. 

the  high  operation  for  stone  before  the  Royal  Society,  of  which 
he  was  a  Fellow.  No  doubt  he,  the  physician,  wrote  on  behalf 
of  his  brother  John,  the  surgeon  and  lithotomist  to  Westminster 
Hospital :  it  was  a  common  practice  in  those  days  for  the 
cultured  physician  to  do  the  literary  work  of  the  practical 
surgeon.  In  1723  John  Douglas  published  his  treatise  on  the 
operation.  Douglas  was  truly  an  inventor.  When  he  began 
working  at  the  operation  he  was  ignorant  of  Roussetus's  work, 
although  he  knew  of  Franco's  bungling  operation.  The  name 
he  adopted,  "  Lithotomia  Douglassiana,"  clearly  indicates  the 
position  he  assumes  ;  and  its  admission  by  his  compeers  shows 
that  they  did  not  grudge  him  the  title  of  inventor.  The  brothers 
were  anatomists  and  scientific  men  of  a  high  order,  and  they 
set  about  working  out  the  anatomical  basis  of  the  operation  in  a 
thoroughly  workmanlike  manner.  He  describes  his  method  in 
ten  pages,  and  relates  three  cases,  with  drawings  of  the  stones. 
The  bladder  is  to  be  filled  with  warm  water ;  the  catheter  being 
withdrawn,  the  assistant  instead  of  grasping  the  penis  bends  it 
"  down  towards  the  anus,  which  will  hinder  the  water  from 
spurting  out,  and  also  keep  his  hand  out  of  the  way."  The  rest 
of  the  operation  is  essentially  that  of  Roussetus.  He  makes 
the  error  of  advising  the  completion  of  the  incision  into  the 
bladder  by  running  the  knife  upwards  towards  the  fundus, 
whereby  the  danger  of  penetrating  the  abdomen  is  increased. 
He  points  out  the  superiority  of  forceps  to  fingers  in  withdraw- 
ing the  stone,  as  the  fingers  take  up  more  room.  Douglas's 
patients  were  shown  at  the  Royal  Society,  and  their  fame  soon 
spread.  He  had  a  good  many  followers  in  England,  some  of 
whom  wrote  treatises  on  the  operation.  The  most  important  of 
these  are  Cheselden  of  London  and  Thornhill  of  Bristol. 

Cheselden  must  have  been  familiar  with  Douglas's  work 
before  Douglas  wrote  his  treatise,  for,  in  1723  he  wrote  his  book 
on  the  high  operation  ;  and  having  greater  opportunities  of  put- 
ting the  operation  into  practice,  he  was  able  to  publish  nine  cases 
of  operation.  His  description  of  the  operation  occupies  ten  small 
pages ;  the  rest  of  the  book  is  occupied  with  descriptions  of  his 
cases  and  dissections,  and  translations  of  the  writings  of  Rousse- 


HISTORY.  647 

tus,  Le  Mercier,  Hildanus,  and  others.  Cheselden  gives  Douglas 
the  credit  of  being,  if  not  "  the  inventor,  surely  the  first  man  that 
ever  practised  it  upon  living  bodies."  Cheselden's  description  of 
the  operation,  though  short  and  somewhat  defective,  is  clear  and 
practical.     It  differs  in  no  important  point  from  Douglas's. 

The  next  important  name  in  the  history  of  the  operation  is 
that  of  Thornhill  of  Bristol,  who  performed  his  first  operation 
in  February,  1722.  When  his  work  was  published  (by  his 
friend  and  colleague  John  Middleton,  physician)  in  1727,  he  had 
operated  on  at  least  fifteen  cases.  In  Thornhill's  (or  Middleton's) 
treatise,  the  description  of  the  operation,  with  some  preliminary 
anatomical  matter,  occupies  23  quarto  pages;  and  his  cases, 
criticisms,  and  plates  occupy  47  pages  more.  The  description 
of  supra-pubic  lithotomy  as  performed  by  Thornhill  is  marvel- 
lously good.  From  his  description  of  how  the  assistant  is  to 
hold  the  penis,  "  with  a  rag  between  the  fingers  and  thumb, 
that  it  may  not  slip  "  ;  his  warning  against  over-distension  of  an 
ulcerated  bladder ;  his  accurate  description  of  the  contraction 
of  the  ends  of  the  recti,  and  how  this  may  be  obviated  ;  the  risks 
of  cutting  upwards ;  the  manner  in  which  the  peritoneal  fold  is 
pushed  downwards  by  straining ;  how  to  keep  up  the  collapsing 
bladder  after  it  is  incised  ;  and,  more  particularly,  by  his  fertility 
of  resource  in  treating  his  cases  and  their  complications :  one 
cannot  avoid  the  conclusion  that  Thornhill  was  in  his  own  time, 
and,  indeed,  for  a  century  and  a  quarter  later,  the  best  exponent 
of  supra-pubic  lithotomy.  He  had  greater  experience  than  any 
of  his  age  ;  he  showed  a  finer  appreciation  of  the  difficulties  and 
peculiarities  of  the  operation  ;  and  undoubtedly,  as  a  perusal  of 
his  cases  must  show,  he  exhibited  more  daring,  and  at  the  same 
time  more  caution,  than  any  of  his  predecessors. '^' 

*  The  excellence  of  Thornhill's  work  so  impressed  me,  that  I  have  taken  a 
good  deal  of  trouble  in  elucidating  his  history.  Fortunately,  there  are  ample 
means  of  doing  so  in  the  very  full  records  of  the  Bristol  Royal  Infirmary,  which 
are  now  in  its  Library.  Thornhill  was  its  first  surgeon,  appointed  in  1737  ; 
and  he  was  the  most  conspicuous  surgeon  of  his  day  in  Bristol.  He  was  highly 
prosperous,  somewhat  of  a  dandy,  almost  independent  of  his  profession ;  a 
brilliant  operator,  but  apparently  careless  of  reputation,  and  following  inde- 
pendently the  bent  of  a  genius  that  was  clearly  somewhat  erratic.  It  was  in 
complete  harmony  with  his  nature  that  he  should  not  take  the  trouble  to  say 
a  word  about  his  work,  but  leave  the  writing  to  his  friend  Middleton. 


6i8  SUPRA-PUBIC   CYSTOTOMY. 

To  give  an  idea  of  the  keenness  of  Thornhill's  insight 
into  the  essentials  of  the  operation,  I  quote  the  following 
remarks,  which  appear  as  a  foot-note  in  his  work  (p.  17) :  "I 
was  in  hopes  that  the  place  for  the  puncture  might  be  fixed  to 
the  satisfaction  of  everybody,  by  searching  gently  with  the 
finger,  for  the  insertion  of  the  urachus  in  the  bottom  of  the 
bladder,  which  in  an  adult  subject  I  have  observed  to  be  pro- 
minent, like  a  little  knob,  pretty  firm,  and  as  big  as  a  large  pea, 
only  somewhat  flatter ;  and  the  finger  being  placed  upon  it,  the 
puncture  might  be  made  immediately  below  it  with  an  absolute 
certainty.  But  I  find  this  direction  is  fallible  in  live  subjects, 
where,  the  fibres  being  all  in  action,  the  part  seems  so  equally 
tense,  that  it  is  hard  to  distinguish  the  insertion  of  the  urachus. 
However,  I  mention  this  as  a  theory,  which  perhaps  may  be 
improved,  and  in  adults  is  not  entirely  to  be  neglected."  This 
is  a  highly  important  observation  which,  so  far  as  I  know,  has 
never  been  made  before  in  respect  of  this  operation.  And  it  is 
literally  correct.  With  a  little  practice  in  the  dead-house,  I 
think  it  is  always  possible  to  make  out  the  insertion  of  the 
urachus :  and  if  we  cut  in  the  middle  line  below  this  point,  we 
cannot  injure  the  peritoneum.  It  must  be  remembered  that  in 
Thornhill's  da}'  there  was  no  anaesthesia. 

Samuel  Pye*  of  Bristol,  in  1725,  wrote  a  small  pamphlet  on 
the  operation,  which  does  little  more  than  show  his  own  failure 
to  grasp  its  principles  or  to  put  it  properly  into  practice.  Of  his 
four  cases,  it  is  noteworthy  that  in  one  he  got  primary  union  of 
the  wounds,  and  the  boy,  aged  five,  was  playing  in  the  street  on 
the  fifteenth  day.  Macgill  of  Edinburgh  wrote  letters  recording 
a  few  cases  to  Middleton  and  to  Cheselden,  which  were  printed 

*  Samuel  Pye  was  a  Bristol  surgeon,  who  had  a  great  reputation  for  the 
treatment  of  venereal  diseases. 

"  The  home-bred  documents  of  Old  Sam  Pye 
Were  standing  rules  to  treat  their  buboes  by." — Chatterton. 

He  was  a  rival  of  Thornhill ;  and  his  pamphlet  was  clearly  directed  mainly 
against  Thornhill  himself.  He  had  very  little  experience  of  the  operation 
(four  cases),  and  his  objections  to  it  were  mostly  fanciful  and  stupid.  "  Old  Sam. 
Pye"  had  the  somewhat  dubious  honour  of  being  reviled  by  Chatterton  in 
an  unpublished,  and  unpublishable,  poem  now  in  the  library  of  the  Bristol 
Royal  Infirmary. 


HISTORY.  649 

in  their  books.  In  France,  Morand  performed  the  operation  on 
Roussetus's  principles,  and  in  1728  wrote  a  treatise  on  "  Cutting 
by  the  High  Apparatus,"  as  it  was  sometimes  called.  Several 
other  surgeons  performed  the  operation,  and  wrote  about  it  at 
this  time ;  but  no  improvement,  scarcely  any  change,  in  the 
method  was  recorded  till  Frere  Come  (or  Cosme),  a  well-known 
lithotomist  in  Paris,  took  it  up.  Come's  book  was  published  in 
1779,  after  he  had  finally  elaborated  his  plan.  He  is  said  to 
have  operated  on  nearl}'  a  hundred  patients,  and  with  almost 
uninterrupted  success.  The  chief  peculiarity  in  Come's  pro- 
ceeding was  the  use  of  the  sonde  a  dard  introduced  into  the 
bladder  through  an  opening  made  in  the  perineum  into  the 
membraneous  urethra.  This  instrument  was  a  curved  hollow 
sound  introduced  through  the  perineal  opening  into  the  bladder  ; 
by  depressing  it  the  point  was  made  to  raise  the  bladder  into  the 
wound,  and  the  concealed  dart  or  stilet  was  made  to  perforate 
the  bladder.  The  aponeurosis  between  the  recti  was  divided  by 
a  curved  knife  with  a  button  point,  which  pushed  the  peritoneum 
in  front  of  it.  Deschamps  suggested  that  the  low  opening  for 
the  introduction  of  the  sound  should  be  made  through  the 
rectum. 

Le  Blanc  in  1773*  is  said  to  have  recommended  opera- 
tion a  deux  temps,  a  proposal  which  was  revived  by  Vidal  de 
Cassis  in  1832,  and  again  quite  recently  by  Neuber  of  Kiel. 
The  advantages  of  the  operation  in  two  stages  are  not  so 
evident  in  the  case  of  the  bladder  as  in  similar  ones  on  the 
intestinal,  tract.  On  the  other  hand,  Professor  Rydygier  of 
Krakow,  ignoring  the  supposed  safety  conferred  by  extra-peri- 
toneal methods,  and  depending  on  the  known  capability  of  the 
peritoneum  for  rapid  union,  has,  quite  recently,  boldly  opened 
the  bladder  through  its  peritoneal  aspect  and  immediately 
sutured  it. 

From  its  early  introduction  almost  to  the  present  day  the 
operation  steadily  declined,  both  in  favour  and  in  mode  of  per- 
formance, and  we  need  not  follow  its  fortunes.*  Its  revival  has 
been  simply  part  of  the  general  revival  of  surgery  which  has 
*   Dulles,  Med.  and  Surg.  Rep.,  Phila.,  June  30,  1888. 


650  SUPRA-PUBIC   CYSTOTOMY. 

marked  the  last  twenty  years.  At  the  present  day  the  operation 
is  where  Douglas  and  Thornhill  left  it — improved  in  the  same 
manner  and  by  the  same  influences  as  other  surgical  operations 
have  been  improved,  and  not  least  in  the  way  of  discarding  all 
ingenious  contrivances  for  doing  away  with  the  necessity  for 
educated  fingers  and  anatomical  knowledge. 

In  quite  recent  days  its  revival  has  really  been  part  of  the 
quiet  resuscitation  of  many  old  and  neglected  operations.  If 
anyone  more  than  another  deserves  credit  for  its  re-introduction, 
it  is  Sir  Joseph  Lister.  But  the  most  conspicuous  stimulus  has 
been  derived  from  the  experiments  of  Garson  and  Petersen  on 
the  influence  of  distension  of  the  rectum  in  increasing  the 
depth  of  the  supra-pubic  interval.  The  real  value  of  this 
invention  is  now  openly  questioned  by  many  surgeons,  while 
there  is  no  doubt  as  to  its  occasional  risk :  but  however  this 
may  be,  their  experiments  have  called  attention  to  the  operation  ; 
and  this  attention  has  assisted  in  placing  the  operation  perma- 
nently among  recognised  surgical  proceedings. 


INDICATIONS    FOR    OPERATION. 

Broadly  it  may  be  said  that  the  supra-pubic  operation  may 
be  called  for  in  dealing  with  any  conditions  which  may  demand 
cystotomy.  Removal  of  stones,  foreign  bodies,  or  tumours  may 
be  carried  out  best  by  the  supra-pubic  operation ;  drainage  of 
an  inflamed  bladder  ;  the  provision  of  an  exit  for  urine  in  obstruc- 
tion of  the  natural  passages ;  the  formation  of  an  artificial 
opening  in  cases  of  malignant  disease  where  suffering  is  caused 
by  obstruction  from  the  clotting  of  blood — may  all  be  indica- 
tions for  operation.  But  they  are  indications  only  in  compe- 
tition with  other  proceedings ;  and  the  comparative  values  of 
these  operations  must  be  estimated. 

Stone  in  the  Bladder. — The   best   operation  for   stone  in  the 
bladder  is  on  all   hands  admitted  to  be  Bigelow's — lithotrity 
with  evacuation  at  one  sitting.      As  experience  increases  and 
*  See  Dulles,  Lancet,  Dec.  3rd,  1887. 


INDICATIONS  FOR   OPERATION.  651 

instruments  are  improved,  the  range  of  Bigelow's  operation  is 
being  extended.  Stones  of  a  very  large  size  are  crushed  by 
powerful  instruments  and  completely  removed  at  one  operation ; 
while,  with  the  help  of  very  delicate  instruments,  stones  are 
now  successfully  removed  from  very  small  children,  almost  from 
infants.  The  operation  of  election  for  stone  in  the  bladder  is 
undoubtedly  Bigelow's :  on  this  there  is  almost  universal 
unanimity. 

Under  certain  circumstances  this  operation  is  out  of  court. 
Thus,  the  stone  may  be  so  hard  that  no  instrument  will  crush  it. 
or  the  process  of  crushing  may  be  attended  with  danger  to  the 
vesical  walls  from  the  flying  off  of  sharp  fragments ;  or  it  may 
demand  such  a  prolonged  operation  that  the  patient's  life  is 
endangered.  Again,  it  may  be  so  large  that  crushing  by  any 
instrument  introduced  by  the  urethra  is  out  of  the  question. 
Or,  in  young  children,  from  smallness  of  the  urethra,  it  may  be 
impossible  or  dangerous  to  pass  efficient  instruments.  Or, 
lastly,  looking  at  the  general  condition  of  the  patient  and  the 
size  of  the  stone,  it  may  appear  that  a  quick  cutting  operation 
gives  the  best  chance  of  recovery.  Then  the  decision  is  one 
between  lateral,  or  at  least  perineal,  lithotomy,  and  the  opera- 
tion over  the  pubes. 

Taking  the  case  of  young  children  first,  we  often  hear  it 
said  that  for  removal  of  stones  in  the  bladder  we  do  not  want 
a  better  operation  than  lateral  lithotom}'.  Recent  work  in  crush- 
ing would  seem  to  show  that  here  we  have  already  got  an  opera- 
tion at  least  as  good  as,  probably  better  than,  lateral  lithotoni}^ ; 
while,  as  regards  remote  results,  there  can  be  no  comparison. 
A  child  who  has  been  cut  for  stone  is  not  safe  from  stricture  of 
the  urethra  as  he  grows  up.  In  the  face  of  actual  facts,  the 
position  of  ignorance  as  to  bad  subsequent  results  after  perineal 
lithotomy  cannot  be  upheld.  In  this  Bristol  district,  where 
stone  is  rare,  I  have  seen  in  the  last  nine  years  five  operations 
for  perineal  fistula  following  perineal  lithotomy,  and  I  have  been 
concerned  in  the  treatment  of  one  case  of  stricture  and  one  of 
fistula  from  the  same  cause.  And  the  treatment  of  these  catas- 
trophes is  not  always  easy  or  successful ;  the  stricture,  at  least, 


652  SUPRA-PUBIC  CYSTOTOMY. 

may  be  said  to  last  during  the  life  of  the  patient.  In  a  very 
successful  operation  for  fistula  after  lithotomy  performed  by 
Mr.  Board  at  the  Bristol  Infirmary,  the  stricture  was  not  marked, 
and  the  result  may  be  said  to  be  curative ;  but  in  all  the  others 
which  I  have  seen  the  operation  did  not  cure  the  stricture- 
Knowing  what  we  do  of  the  causation  and  results  of  trau- 
matic stricture  of  the  urethra,  it  is  surprising  that  evil  effects 
so  seldom  follow  perineal  lithotomy  in  children.  Sexual  in- 
competence, or  rather  sterility,  must  also  be  reckoned  among 
the  possible  effects.  Haemstadt,  according  to  MacCormac,* 
found  that  of  eighteen  married  men  who  had  had  lithotomy 
performed  in  childhood,  only  one  had  children. 

Stricture,  fistula,  sexual  incompetence — separately  or  com- 
bined— must  be  admitted  to  be  rare  sequences  of  perineal 
lithotomy.  But  that  they  are  possible  sequences  cannot  be 
denied.  Now  if  the  supra-pubic  operation  can  show  immediate 
results  as  good  as  the  perineal,  and  a  complete  absence  of 
remote  drawbacks,  then  the  supra-pubic  operation  should  be 
selected.  Even  if  the  per-centage  against  the  perineal  were  as 
small  as  one,  this  one  case  for  fixing  a  rule  in  sound  surgery 
should  be  decisive.  In  children,  therefore,  I  should  say  that 
where  the  crushing  operation  is  negatived,  the  supra -pubic 
should  be  adopted.  A  further  argument  in  favour  of  its  adop- 
tion in  children  is  the  favourable  position  of  the  bladder,  and 
the  usually  healthy  condition  of  the  involved  tissues. 

In  the  case  of  adult  males,  the  size  of  the  stone  and  the 
condition  and  age  of  the  patient  have  most  influence.  Pro- 
longed anaesthesia  for  crushing  and  evacuation  is  full  of  danger 
for  old  or  enfeebled  patients ;  and  stones  over  two  ounces 
in  weight  are  best  removed  by  the  supra-pubic  route.  Very 
large  stone,  must  be  removed  in  this  way.  Indeed,  the  size 
of  the  stone  would  seem  scarcely  at  all  to  influence  the 
death-rate  in  this  operation.  The  patient  from  whom  Mr. 
T.  Smith  removed  a  stone  weighing  24^  ounces  made  a  better 
recovery  than  Sir  Henry  Thompson's  patient,  whose  stone 
weighed  14^  ounces.  Here  the  operation  is  one  of  necessity, 
*  Lancet,  Mar.  ig,  1887. 


INDICATIONS  FOR  OPERATION.  653 

not  of  choice.  Such  enormous  stones  can  be  removed  neither 
by  crushing,  nor  by  cutting  through  the  perineum. 

For  encysted  stone  the  supra-pubic  operation  has  been  pro- 
perly commended. 

In  elderly  patients  with  stones  which  it  is  either  impossible 
or  unwise  to  crush,  it  is  mainly  a  question  of  saving  of  life.  In 
very  young  patients  it  is  not  so  much  a  question  of  saving  life — 
all  the  operations  are  comparatively  safe  in  this  respect — as  of 
permitting  an  existence  free  from  future  trouble.  Now,  the 
drawbacks  after  perineal  lithotomy,  if  small,  are  undoubtedly 
present :  after  supra-pubic  lithotomy  they  are  simpty  non- 
existent. It  is  probable  that  increasing  perfection  of  instru- 
ments will  admit  of  crushing  in  male  children  of  the  most 
tender  age  ;  but  a  small  proportion  must  always  remain  where 
a  cutting  operation  is  best.  This  operation,  with  the  evidence 
before  us,  should  nearly  always  be  the  supra-pubic  one.  For 
cases  in  advanced  life,  or  with  large  stones,  the  operation 
should,  in  the  majority  of  instances,  be  the  supra-pubic  one. 

In  the  case  of  females  with  stone  in  the  bladder,  the  question 
of  supra-pubic  cystotomy  is  not  so  frequently  presented  to  us. 
The  stone  must  be  a  very  large  one  which  cannot  be  crushed 
through  the  female  urethra.  For  stones  of  moderate  size  which 
are  too  hard  to  crush,  incision  of  the  urethra,  with  dilatation  of 
the  neck  of  the  bladder,  and  subsequent  immediate  suturing  of 
the  divided  urethra,  is,  in  my  opinion,  a  simpler  and  better 
operation  than  supra-pubic  cystotomy.  Incision  through  the 
bladder  and  vagina  is  not  a  commendable  operation.  For  very 
large  stones,  four  ounces  and  upwards,  the  supra-pubic  operation 
is  probably  the  best. 

Nothing  need  here  be  said  as  to  the  symptoms  and  diagnosis 
of  vesical  calculus. 

Foreign  Bodies. — Here  the  operation  selected  must  depend  on 
the  nature  of  the  foreign  body  present.  In  most  cases  the  call 
to  operate  is  not  made  till  the  body  is  coated  more  or  less  com- 
pletely with  phosphates,  and  in  many  the  body  is  completely 
buried  in  the  heart  of  a  stone.     In  the  second  case,  if  a  cutting 


654  SUPRA-PUBIC  CYSTOTOMY. 

operation  is  decided  upon,  it  is  lithotomy  pure  and  simple  ;  but 
if  lithotrity  is  the  operation  selected,  and  the  foreign  body  is 
metallic,  then  crushing  may  result  in  failure.  Of  course,  if  it  is 
known  that  a  foreign  body  is  present  that  cannot  be  crushed, 
this  calamity  may  be  avoided. 

In  those  cases  where  attention  is  called  to  the  presence  of 
the  foreign  body  very  soon  after  it  has  been  introduced,  and  the 
nature  of  it  is  known,  attempts  may  be  made  to  extract  it  by 
means  of  any  of  the  ingenious  Redressors,  or  Basculeurs,  or 
Duplicators,  or  special  forceps  invented  for  the  purpose.  The 
success  which  has  followed  the  use  of  these  and  such  instru- 
ments in  removing  foreign  bodies  from  the  bladder  has  been 
most  encouraging.  In  Denuce's  collection  of  249  cases  of  foreign 
bodies  which  had  necessitated  lithotomy  or  extraction,  there 
were,  prior  to  1830,  100  cases  of  lithotomy  and  27  of  extraction  ; 
while,  subsequently  to  1830,  there  were  only  21  lithotomies,  the 
rest  being  extractions.  Poulet  found  in  a  fuller  analysis  a  some- 
what greater  proportion  of  lithotomies.  He  points  out  that 
simple  extraction  is  by  no  means  so  free  from  danger  as  might 
be  supposed ;  that  the  bladder  or  the  passage  may  readily  be 
wounded ;  and  that,  on  the  whole,  there  is  not  much  to  choose 
between  cutting  and  extracting,  at  least  so  far  as  the  male 
bladder  is  concerned.  In  the  case  of  the  female  bladder,  if 
dilatation  of  the  urethra  is  employed  and  the  bladder  explored, 
extraction  is  a  far  safer  proceeding. 

Any  attempt  to  give  definite  rules  for  the  selection  of  the  best 
mode  of  removing  foreign  bodies  must  fail  in  the  face  of  their 
almost  endless  variety.  Generally  speaking,  if  the  foreign  body 
is  very  long,  if  it  is  composed  of  brittle  material,  such  as  a  glass 
tube,  and  more  especially  if  its  ends  are  sharp,  or  perhaps  em- 
bedded in  the  vesical  walls,  the  supra-pubic  operation  is  the  best 
to  select.  In  cases  where  there  is  evidence  of  perforation  of  the 
bladder,  the  supra-pubic  operation  must  be  extended  to  ab- 
dominal section  in  order  that  the  rent  may  be  sutured.  Evidence 
of  perforation  of  the  bladder  usually  follows  closely  on  the 
occurrence  of  the  injury.  In  some  cases,  however,  perfora- 
tion takes   place  very  slowly  by  ulceration,   and   reaches   the 


INDICATIONS   FOR   OPERATION.  655 

general  cavity  only  after  the  formation  of  peri-vesical  abscess. 
In  an  extraordinary  and  probably  unique  case  which  I  have 
recorded  elsewhere,"  one  end  of  the  rib  of  an  umbrella,  two 
inches  in  length,  lay  among  the  intestines,  while  the  other  ex- 
tremity was  inside  the  bladder  embedded  in  a  phosphatic  stone 
of  the  size  and  shape  of  a  plover's  egg.  The  patient,  a  lunatic, 
had  exhibited  no  symptoms  of  its  presence,  and  died  from  another 
cause.  Here  abdominal  section  would  have  been  essential  to 
the  proper  completion  of  the  operation,  for  in  no  other  way 
could  the  perforation  have  been  closed. 

There  can  be  no  doubt  that  the  removal  of  a  sharp  or  large 
foreign  body  may  be  carried  out  with  less  risk  of  wounding  the 
vesical  walls  by  the  hypogastric  than  by  the  perineal  method. 
There  is  more  room  ;  the  whole  body  is  within  easy  reach  of  the 
finger,  and  perhaps  may  be  brought  into  view  ;  and  it  is  easy  to 
ascertain  whether  the  bladder  is  wounded.  The  whole  question 
is  one  which  must  be  left  to  the  discretion  of  the  surgeon,  acting 
upon  such  information  as  to  the  nature  of  the  foreign  body  as  he 
can  gather.  The  operation  selected  should  be  one  by  which  the 
foreign  body  can  certainly  be  removed ;  it  is  little  less  than  a 
catastrophe  to  have  to  resort  to  the  supra-pubic  route  when  the 
perineal  fails.  All  such  tentative  surgery  is  to  be  sternly  con- 
demned. There  is  little  to  choose  as  regards  actual  mortality 
between  the  supra-pubic  and  the  perineal  operation  ;  if  tliere  is 
the  slightest  doubt  that  one  will  fail,  the  other,  which  cannot 
fail,  should  unhesitatingly  be  adopted. 

Tumours  of  the  Bladder. — An  accurate  and  exhaustive  classifi- 
cation of  tumours  of  the  bladder  has  yet  to  be  made.  Sir 
Henry  Thompson,!  working  upon  such  material  as  lay  to  his 
hand,  has  given  a  classification  which  is  admittedly  tentative  and 
temporary.  Looking  at  such  growths  in  the  broadest  possible 
aspect,  I  think  the  best  and  simplest  division  is  into  polypus, 
papilloma,  and  cancer.  For  clinical  purposes  this  division  is 
certainly  satisfactory  ;  and  it  is  not  unlikely  that,  with  minor 

*  Bristol  Med.-Chir.  Journ.,  March,  1886. 
+  Tumours  of  the  Bladder,     London,  1884. 


656  SUPRA-PUBIC   CYSTOTOMY. 

subdivisions,  it  might  be  made  to  include  all  known  varieties  of 
bladder-growth. 

Polypus  is  almost  peculiar  to  the  bladder  of  children.  In 
structure  it  is  practically  identical  with  the  simple  mucous  poly- 
pus found  on  the  nasal  and  other  mucous  membranes.  Some 
of  them  contain  much  mucoid  substance,  being  practically  myxo- 
mata;  while  others  are  more  dense,  containing  varying  quantities 
of  fibrous  tissue.  These  polypi  are  often  found  in  great  numbers, 
sometimes  filling  and  even  distending  the  bladder. 

Papilloma,  also  termed  "Villous  Tumour,"  is  the  best  known 
of  bladder-growths.  It  is  by  no  means  uniform  in  appearance. 
In  some  it  is  represented  by  an  exceedingly  fine,  almost  impalp- 
able, growth  of  fimbriae  or  papillae,  set  upon  a  narrow  pedicle 
and  spreading  out  into  a  more  or  less  distinct  mass,  not  unlike  a 
cauliflower  in  shape.  Sometimes  these  fine  growths  are  single, 
oftener  they  are  multiple,  being  three  or  more  in  number;  rarely 
they  are  found  scattered  over  the  whole  of  the  cavity.  Each 
papilla  or  villus  consists  of  a  fine  basement  membrane  containing 
blood-vessels,  covered  by  several  layers  of  columnar  cells  iden- 
tical with  those  covering  the  mucous  membrane  of  the  bladder. 
The  villi  are  about  the  same  thickness  from  base  to  apex ;  the 
apex  of  the  whole  growth  is  broader  than  the  base,  on  account  of 
their  dividing  as  they  grow.  The  vascular  v/alls  are  very  thin, 
and  easily  ruptured.  Thompson  calls  this  variety  the  Fimbriated 
Papilloma.  A  second  variety,  in  which  the  fibrous  tissue  at  the 
base  of  the  growth  (which,  by  the  way,  usually  contains  in- 
organic fibre)  is  in  considerable  amount,  forming  a  conspicuous 
part  of  the  tumour,  he  calls  Fibro-papilloma.  Some  tumours 
described  as  myoma  would  probably  belong  to  this  category. 
Here  the  fine  fimbriae,  though  present,  are  not  usually  so  long 
or  so  perfectly  developed  as  in  the  previous  variety.  In  a  third 
variety  the  fibrous  material  at  the  base  is  still  further  developed, 
and  exhibits  in  its  meshes  material  suggestive  of  malignancy. 
It  is  doubtful,  however,  whether  real  malignancy  could  be  proved, 
in  these  cases,  by  any  test  other  than  tendency  to  recur,  which 
of  course  may  also  be  described  as  continued  growth  after  in- 
complete removal. 


PAPILLOMA    OF  BLADDER.  657 

All  forms  of  malignant  disease  have  been  found  invading  the 
bladder.  Sarcoma  is  rare,  although  not  so  rare  as  is  generally 
supposed  (Southam) ;  encephaloid  has  been  met  with ;  scirrhus 
of  the  bladder  proper  has  been  described,  but  is  usually  an 
extension  from  a  primary  invasion  of  the  prostate  ;  epithelioma 
is  probably  the  most  common  form  of  malignant  disease  met 
with. 

Dermoid  tumour  has  been  found  in  the  bladder,  as  in  most 
other  structures ;  and  one  case  is  recorded  in  which  Bryant 
successfully  removed  such  a  growth  from  the  female  bladder. 

The  symptoms  of  polypus  in  the  bladder  in  children  have 
usually  been  those  of  stone,  with  more  than  the  ordinary 
amount  of  tenesmus,  and  with,  perhaps,  more  frequent  attacks 
of  tenesmus. 

The  symptoms  of  papilloma  are  very  well  known,  and 
usually  sufficiently  definite  to  make  a  diagnosis  highly  probable. 
Still,  exceptions  exist  where  diagnosis  is  rendered  certain  only 
during  operation.  Symptoms  impress  men  differently.  I  have 
removed  a  papillomatous  growth  from  the  bladder  of  a  lady 
who  was  for  three  years  treated  by  distinguished  men  for 
"gouty  kidney."  A  colleague  who  diagnosed  the  case,  and 
sent  me  the  patient,  concluded  it  was  papilloma  after  a  few 
minutes'  conversation  with  the  patient.  Much,  therefore,  de- 
pends on  the  point  of  view  from  which  one  looks  at  symptoms. 

The  first,  the  last,  and  usually,  but  not  always,  the  only 
continuous  symptom  of  papilloma  is  hajmaturia.  In  some  cases 
it  is  positively  the  only  symptom,  the  patient  showing  no  signs 
of  bladder  irritation  or  inflammation  or  other  trouble  beyond 
bleeding,  and  dying  in  the  end  simply  from  loss  of  blood.  In  most 
cases,  however,  there  is  increased  frequency  of  micturition;  occa- 
sionally there  is  tenesmus ;  and  in  some  cases,  where  the  blood 
coagulates  in  the  bladder,  there  is  complete  retention,  with  con- 
stant and  ineffectual  attempts  to  empty  the  bladder.  In  one 
case  I  had  to  scoop  out  with  the  fingers  enormous  quantities 
of  clot,  which  distended  the  bladder,  before  I  could  reach  the 
tumour.     The  haemorrhage  is  least  profuse  in  the  early  stages 

43 


658  SUPRA-PUBIC  CYSTOTOMY. 

and  increases  in  amount,  not  steadily  but  with  remissions,  as  the 
disease  advances. 

In  the  earher  stages  the  haemorrhage  sometimes  makes  its 
appearance  in  a  manner  which  is  highly  characteristic.  The 
water  first  passed  is  clear,  or  but  slightly  tinged  with  blood  ; 
towards  the  end  of  micturition  the  tint  becomes  a  brighter  red, 
and  as  the  act  ceases,  a  few  drops  or  a  little  stream  of  pure 
blood  comes  away,  with  some  pain  and  straining.  This  appear- 
ance is  no  doubt  produced  by  compression  of  the  tumour  by  the 
contracting  bladder  and  rupture  of  some  of  its  thin-walled 
vessels.  As  the  bladder  refills,  the  villi,  soaking  in  the  urine, 
go  on  bleeding,  and  cause  a  general  admixture  of  blood,  or  the 
formation  of  small  or  large  coagula  according  to  the  amount  of 
blood  discharged. 

Passing  the  sound  in  cases  of  papilloma  usually  gives  nega- 
tive results.  The  finger  in  the  rectum  if  the  patient  is  a  male, 
in  the  vagina  if  a  female,  follows  the  sound  as  it  is  moved  about, 
and,  through  the  mucous  membranes,  estimates  the  even  thick- 
ness of  the  bladder- walls,  and  notes  any  fulness  or  induration 
between  it  and  the  metal.  Only  large  and  firm  papillomata 
can  be  detected  in  this  way. 

It  is  important  to  make  frequent  and  careful  microscopical 
examinations  of  the  urine,  with  a  view  to  the  discovery  of 
portions  of  the  fimbriae  which  are  constantl}^  being  shed.  The 
sediment  from  one  or  two  days'  urine  is  permitted  to  settle, 
washed  to  get  rid  of  the  blood,  and  examined  in  detail.  Sir 
Henry  Thompson  makes  the  useful  suggestions,  that  the  bladder 
should  be  washed  out  freely  with  warm  water,  or  that  a  lithotrity 
evacuator  should  be  used  to  obtain  portions  of  the  growth  for 
examination.  The  finding  of  fimbrae  in  the  urine  is  patho- 
gnomonic. The  use  of  the  lithotrite  to  grasp  and  remove 
portions  of  the  growth  is  a  somewhat  haphazard  proceeding. 

In  the  case  of  epithelioma  of  the  bladder,  signs  of  vesical 
irritation  come  on  early  and  are  more  urgent  than  in  papilloma. 
Bleedmg  is  more  variable  as  regards  both  occurrence  and 
amount.  Pus  is  found  in  considerable  quantities  in  the  urine, 
and  if  there  is  much  irritation,  ropy  mucus  as  well.     Pain  is  a 


ELECTRIC  ENDOSCOPY.  659 

fairly  constant  and  often  urgent  symptom,  referred  frequently 
to  the  hypogastrium,  and  often  to  outtying  regions,  as  the  point 
of  the  penis  and  down  the  nerves  of  the  thigh.  A  tumour  or 
thickening  may  sometimes  be  palpated  between  the  sound  in  the 
bladder  and  the  finger  in  the  rectum  or  vagina.  Fragments  of 
the  growth  discovered  in  the  urine,  or  in  water  after  washing 
out  the  bladder,  may  confirm  the  diagnosis.  As  to  the  means  of 
diagnosing  other  forms  of  malignant  growth,  there  is  little 
beyond  general  principles  to  guide  us. 

It  would  seem  that  we  are  now  in  the  way  of  obtaining,  if 
we  have  not  already  obtained,  a  really  useful  method  of  exploring 
the  cavit}'  of  the  bladder  by  means  of  the  electric  light.  Accord- 
ing to  Hurry  Fenwick,*  the  incandescent  lamp  cystoscope  of 
Nitze  or  Leiter  is  an  instrument  of  real  practical  utility,  by 
means  of  which  the  whole  cavity  may  be  visually  inspected. 
I  have  not  much  personal  experience  of  the  instrument ;  a  full 
description  of  it  and  the  manner  of  using  it  is  given  by  Fenwick 
in  his  work  and  in  the  papers  referred  to.  Some  practice  with 
the  instrument  on  the  dead  subject  and  on  artificial  bladders  is 
advisable  before  employing  it  in  the  living. 

As  to  the  occurrence  of  these  growths:  polypus  is  apparently 
almost  confined  to  3^oung  children ;  papilloma  is  found  most 
frequently  in  adult  males ;  epithelioma,  while  equally  frequent 
in  both  sexes,  is  probably  most  common  in  late  life.  No  part  of 
the  bladder  has  immunity  from  these  growths ;  all  of  them  are 
most  frequently  found  in  the  base  and  fundus,  and  this  holds 
true  more  especially  of  epithelioma. 

In  every  case  where  polypus  or  papilloma  of  the  bladder  is 
diagnosed,  operation  (with  the  ordinary  exceptions)  is  indicated. 
In  the  case  of  males,  I  consider  that  the  operation  selected 
should  be  supra-pubic  cystotomy.  In  the  case  of  females, 
removal  should  be  attempted  through  the  urethra,  except  in  the 
case  of  very  large  or  very  numerous  growths  spread  over  the 
general  surface  of  the  mucous  membrane.  Setting  the  question 
of  operation  on  the  female  aside  for  the  moment,  we  may  now 

'Electric  Endoscopy,  Lond,   1888,  and  Brit.  Med.  Jonrn.,  Feb.  4th,   1S88,  and 

May  4th,  18S9. 

43  •■'= 


660  SUPRA-PUBIC   CYSTOTOMY. 

discuss  shortly  the  reasons  for  selecting  the  supra-pubic  opera- 
tion in  the  male. 

The  problem  is  a  double  one :  firstly,  by  what  route  may 
tumours  of  the  bladder  most  easily  be  reached ;  and,  secondly, 
by  what  route  can  they  most  readily  and  uniformly  be  removed  ? 
In  answer  to  the  first  question,  the  present  position  of  the 
surgical  mind  is  probably  not  in  harmony  with  the  most  recent 
surgical  writings.  Thus,  in  1884,  Sir  Henry  Thompson'"''  de- 
clared emphatically  in  favour  of  the  median  perineal  route. 
The  finger,  carried  through  the  perineal  opening,  is,  he  says, 
practically  always  capable  of  exploring  the  whole  cavity,  par- 
ticularly with  the  help  of  a  "a  strong  and  determined  assistant" 
to  push  the  contents  of  the  pelvis  downwards.  That  the  whole 
bladder  may  be  explored  with  the  finger-tip  in  this  way,  there 
can  be  no  dispute;  but  in  the  case  of  fat  patients  with  power- 
ful abdominal  muscles,  the  proceeding  must  be  more  one  of 
muscular  strength  than  of  delicate  palpation.  But  that  it  can 
be  compared  with  the  supra-pubic  method  as  regards  ease  or 
thoroughness,  no  one  who  has  tried  the  two  plans  will  admit. 
Every  part  of  the  bladder,  after  the  "  Sectio  alta,"  can  be  ex- 
plored with  the  greatest  ease  b}^  the  finger,  and  much  of  its 
surface  can  be  brought  within  the  range  of  vision.  No  force  is 
required  to  push  up  perineum,  or  press  down  parietes ;  the 
bladder  lies  ready  and  open  to  the  finger. 

And  in  all  seriousness  it  may  be  asked.  What  is  the  use  of 
exploring  the  bladder  at  all,  except  to  proceed  to  removal  of  the 
tumour  ?  I  have  already  in  this  work  protested  against  the  too 
prevalent  fashion  of  "exploratory  operations":  an  exploratory 
operation  on  the  bladder  that  cannot  at  once  be  converted  into 
the  best  curative  operation  should  be  condemned  offhand. 
Exploration  and  removal  should  go  together. 

As  to  facility  of  removal,  there  can  be  no  doubt  that  for  the 
great  majority  of  tumours  the  supra-pubic  operation  is  better 
than  the  perineal.  A  few  tumours  could  be  removed  only  in 
this  way;  and  as  it  is  rarely  possible  exactly  to  locate  a  tumour 
before  operation,  we  should  select  the  mode  of  operation  which 
*  Tumours  of  the  Bladder,  p.  11. 


REMOVAL   OF  GROWTHS.  661 

will  always  succeed.  Some  operations  begun  as  perineal  have 
had  to  be  concluded  as  supra-pubic  :  this  ought  never  to  occur. 
Although  there  is  probably  little  to  choose  as  regards  immediate 
mortality  between  the  high  and  the  low  operation,  there  can  be 
no  doubt  that  a  combination  of  the  two  is  infinitely  worse  than 
either  separately.  If  in  every  case  where  a  tumour  can  be 
removed  by  the  low  operation,  it  can  also  be  removed  by  the 
high ;  if  in  some  cases  (not  diagnosable  beforehand)  the  tumour 
could  be  perfectly  removed  only  by  the  high  route  ;  and  if,  in 
every  case,  manipulation  is  easier  and  more  precise,  the  decision 
in  favour  of  supra-cubic  cystotomy  for  removal  of  tumours  in 
the  male  bladder  cannot  be  in  doubt. 

In  the  case  of  the  female,  I  think  the  best  routine  method  is 
to  proceed  by  incision  of  the  outer  urethra,  followed  by  suture 
after  operation,  with  dilatation  of  the  neck  of  the  bladder.  It 
is  surprising  how  this  division  of  the  outer  urethra,  liberating 
the  finger  from  constriction  and  setting  free  an  invaluable  inch 
or  so  of  its  length,  facilitates  exploration  of  the  vesical  cavity. 
The  operation  is  a  trifling  one  as  compared  with  the  low  opera- 
tion in  the  male,  the  bladder  is  rendered  more  accessible, 
and  in  a  far  less  proportion  of  cases  will  there  be  failure  to 
remove  the  growth.  Still,  the  high  operation  in  women  may 
be  called  for  in  certain  rare  cases  of  mal-posed  and  large-sized 
growths. 

Supra-pubic  cystotomy  has  been  proposed  and  carried  out 
as  an  exceptional  operation,  (i)  as  a  means  of  drainage  in  cys- 
titis ;  (2)  as  a  mode  of  exit  for  the  urine  when  it  cannot  be 
passed  by  the  urethra ;  (3)  by  McGill  of  Leeds  for  the  purpose 
of  removmg  hypertrophied  lobes  of  the  prostate  bulging  into 
the  bladder  and  obstructing  the  flow  of  urine ;  and  (4)  by 
Mr.  W,  Thomson  of  Dublin  as  a  means  of  cure  in  otherwise 
incurable  perineal  fistula.  It  is  impossible  within  the  limits  of 
this  work  to  discuss  these  proceedings.  The  one  operation  of 
"  Prostatectomy,"  as  it  has  been  called,  seems  to  me  to  have 
proved  the  possibility  of  dealing  satisfactorily  with  a  very 
troublesome  condition  which  is  irremediable  by  other  means. 
Experience  alone  will  show  its  value.     Thus  far,  although  the 


662  SUPRA-PUBIC  CYSTOTOMY. 

mortality  has  not  been  very  low,  the  success  as  regards  relief  of 
symptoms  has  been  encouraging.  For  the  relief  and  subsequent 
treatment  of  certain  cases  of  retention,  particularly^  when  depend- 
ing on  enlarged  prostate,  Packard  of  Philadelphia  has  performed 
some  very  successful  hypogastric  sections. 


ANATOMICAL    CONSIDERATIONS. 

The  part  of  the  bladder  concerned  in  this  operation  is  that 
portion  which  lies  behind  the  pubes,  between  the  neck  and  the 
insertion  of  the  urachus.  Betv/een  the  anterior  wall  of  the 
bladder  behind,  and  the  posterior  surface  of  the  pubic  bones 
and  the  abdominal  muscles  in  front;  is  a  pyramidal -shaped 
space  filled  with  connective  tissue  and  blood-vessels  :  in  and 
around  this  space  take  place  the  surgical  manipulations  in  this 
operation.  This  space  varies  in  size  and  shape,  not  only  ana- 
tomically in  different  individuals  and  at  different  ages,  but 
also  according  to  the  condition  of  the  bladder  as  to  emptiness 
or  distension. 

The  posterior  wall  of  the  sheath  of  the  rectus  definitel}'^ 
ends  at  the  curved  margin  of  the  semi-lunar  fold  of  Douglas, 
between  the  umbilicus  and  the  pubes ;  from  this  margin  arise 
two  laj'ers  of  fascia,  which  pass  downwards  between  the  rectus 
and  the  peritoneum.  The  anterior  layer  is  continued  as  a  thin 
covering  to  the  rectus  and  pyramidalis,  and  lines  the  space 
between  the  bladder  and  the  symphysis  pubis  (Braune) ;  the 
posterior  lamina  passes  across  behind  the  urachus  on  to  the 
bladder,  in  order  to  invest  it,  and  to  join  the  prostatic  capsule 
and  pelvic  fascia.  Into  the  potential  space  between  these  two 
laminae  the  expanding  bladder  arises :  they  may,  in  fact,  be 
regarded  as  the  fascial  boundaries  of  the  area  of  operation. 
On  the  posterior  lamina  lies  the  peritoneum,  following  it  in  all 
its  movements. 

The  parietal  peritoneum  is  reflected  on  to  the  bladder  at  its 

summit,  at  a  point  which,  in  the  middle  line,  alwa3'S  corresponds 

.  to  the  insertion  of  the  urachus.    Behind  this  point  the  peritoneum 

is  firmly  attached  to  the  bladder-wall ;  in  front  of  it,  the  peri- 


SURGICAL   ANATOMY.  663 

toneum  can  scarcely  be  said  to  be  attached  to  the  bladder  at  all, 
though,  when  the  bladder  is  empty,  it  lies  closely  apposed  to  its 
anterior  surface  as  low  down  almost  as  the  neck  of  the  organ. 
The  level  at  which  the  peritoneum  is  reflected  from  the  parietes 
on  to  the  bladder  may  be,  as  regards  the  bladder  itself,  at  any 
point  between  the  neck  and  the  fundus,  as  high  up  as  its  summit 
represented  by  the  insertion  of  the  urachus.  As  regards  the 
parietes,  the  level  of  peritoneal  reflexion  is  more  variable,  but 
may  extend  to  any  distance  between  zero  and  three  inches 
above  the  pubes. 

Distension  of  the  bladder  is  the  palpable  means  of  elevating 
this  peritoneal  fold ;  and  as,  almost  from  the  earliest  conception 
of  the  operation,  the  danger  of  wounding  the  peritoneum,  and 
this  means  of  avoiding  it,  were  fully  recognised,  it  might  be 
supposed  that  the  anatomical  descriptions  would,  by  this  time, 
have  been  exhaustive.  They  are  certainly  abundant,  but  they 
are  by  no  means  harmonious. 

One  of  the  earliest  proved  points  was,  the  difference  in  the 
shape  and  position  of  the  child's  bladder  as  compared  with  that 
of  the  adult.  In  1756,  Heuermann  of  Copenhagen'''  pointed 
out  that  the  child's  bladder  was  more  elongated  than  the 
adult's ;  that  it  was  practically  an  abdominal  and  not  a  pelvic 
organ  ;  and  that  the  peritoneal  reflexion  from  it  when  the  bladder 
was  full  rose  higher  than,  and  when  empty  did  not  descend  so 
low  as,  in  the  adult. 

Cruveilhier,  Malgaigne,  Richet,  Paulet,  Sappe}',  and  others 
made  observations  on  the  anatomy  of  the  bladder  in  confirma- 
tion and  extension  of  the  views  of  Heuermann.  I\Iore  recently 
Langer,t  Chauvel,:[:  Mannheim, $  and  others  have  devoted  special 
attention  to  the  subject. 

The  topographical  anatomy  of  the  bladder  in  general,  and 
more  particularly  in  adults,  has  in  the  last  twenty  years  received 
important  additions  from  the  study  of  frozen  sections.     Those 

*  See  Gross  of  Nancy,  Metn.  Coiigi'cs  Franqais  de  Chir.,  1887,  ame  Sess.  1886. 

t  Zeit.  der  Gesellsch,  der  Aertzte  in  Wein,  1882. 

\  Art.  "  Cystotomie,"  Diet.  Encyc.  des  Sc.  Med.,  xxv.,  p.  106. 

§  Uebey  den  Hohensteinschnitt  bei  Kinderen,  Berlin,  1884. 


664  SUPRA-PUBIC  CYSTOTOMY. 

of  Pirogoff  and  Braune  are  among  the  best  known  ;  and  among 
their  followers,  special  mention  must  be  made  of  Garson,  who 
devoted  particular  attention  to  the  bladder  during  emptiness 
and  distension,  and  also  when  displaced  by  an  air-bag  distended 
in  the  rectum.  Garson's  sections  were  made  in  Vienna  in  1877, 
and  his  paper  was  read  by  Braune  at  the  Congress  of  German 
Surgeons  in  1878."  Petersen  of  Kiel  heard  Garson's  paper,  and 
used  on  the  living  body  the  rectal  bag  as  Garson  had  used  it  on 
the  dead.f  The  practice  of  rectal  distension  seems  to  have 
rivetted  the  attention  of  surgeons  ;  and  the  general  revival  of 
the  operation  may  be  said  to  date  from  the  reading  of  Garson's 
paper  in  1878,  or  more  correctly  perhaps  from  the  publication 
of  Petersen's  paper  in  1880. 

In  respect  of  all  these  studies  in  children  and  in  adults,  I  am 
bound  to  say  that  a  perusal  of  most  of  them  does  little  more  than 
convince  one  that  the  topography  of  the  bladder  is  surely  the 
most  variable  in  all  human  anatom3^  It  would  be  both  tedious 
and  unprofitable  to  recapitulate  all  the  measurements  which 
have  been  given ;  I  shall  therefore  shortly  summarise  the 
average  results. 

In  children  up  to  eight  years  of  age  the  peritoneal  fold,  when 
the  bladder  is  empty,  never  descends  below  the  upper  margin  of 
the  pubes,  and  often  rises  a  few  lines  higher ;  with  a  distended 
bladder  the  fold  will  rise,  according  to  the  degree  of  distension, 
from  one  to  two  and  a  half  inches  above  the  pubes.  Now, 
as  a  supra-pubic  space  uncovered  by  peritoneum  of  two  inches 
in  length  can  never  be  necessary  in  the  performance  of  the  supra- 
pubic operation  in  children,  and  a  space  of  an  inch  or  an  inch 
and  a  half  is  quite  sufficient  for  all  practical  purposes,  it  is  clear 
that,  in  children  at  least,  there  is  no  difficulty  whatever,  with 
moderate  distension  of  the  bladder,  in  avoiding  the  peritoneum. 
In  the  300  operations  on  young  children  collected  by  Gross  of 
Nancy,  there  were  only  nine  cases  of  wound  of  the  peritoneum, 
and  only  four  deaths  in  consequence.  When  we  recollect  that 
most  of  these  operations  were  performed  in  the  last  centur}-, 

*  Archiv.f.  Anat.,  1878,  and  Edin.  Med.  Joiirn.,  Oct.,  1S78. 
t  Archiv,  f.  Klin.  Chiv.,  1S80,  xxv. 


SURGICAL   ANATOMY.  665 

we  must  admit  that  the  risk  of  wounding  the  peritoneum,  in 
children  at  least,  is  very  small.  As  a  matter  of  fact,  a  surgeon 
with  some  experience  in  abdominal  work  would  treat  very  lightl}^ 
the  risk  of  wounding  the  peritoneum  in  children  ;  indeed,  the 
operation  would  seem  to  be  equally  easy  in  these,  whether  the 
bladder  is  distended  or  not. 

As  regards  adults,  these  statements  must  be  modified  a 
little.  The  neck  of  the  bladder,  the  internal  orifice  of  the 
urethra,  in  male  adults  lies  about  two  inches  below  the 
upper  margin  of  the  pubes.  Now,  the  peritoneum  between  the 
pubes  and  the  bladder  cannot  descend  lower  than  the  external 
longitudinal  muscular  layer  of  the  bladder,  which  is  inserted 
into  the  lower  border  of  the  pubes.  This  distance  is  nearl}^ 
always  under  an  inch  in  length.  Indeed,  in  most  the  reflexion 
of  peritoneum  in  a  perfectly  empty  bladder  takes  place  very 
near  to  the  upper  margin  of  the  pubic  bones.  In  old  men  it  is 
lowest,  and  in  these  sometimes  the  whole  upper  surface  of  the 
bladder  appears  cupped  and  concave,  without  the  appearance 
of  any  peritoneal  folding  at  all.  With  Barwell,*  I  cannot  believe 
it  other  than  impossible  that  the  peritoneal  fold  could  lie  as  low  as 
two  and  a  quarter  inches  below  the  upper  margin  of  the  os  pubis. 

This  refers  to  the  lower  limit  of  the  peritoneal  fold  in  the  con- 
tracted state  of  the  bladder  ;  we  must  now  turn  to  the  effects  of 
distension  of  the  bladder  alone,  and  of  this  combined  with  in- 
flation of  a  bag  in  the  rectum.  Of  the  influence  of  distension 
of  the  bladder  in  raising  the  fold  there  is  no  doubt  whatever. 
With  different  degrees  of  distension,  that  is  to  sa3^  after  injec- 
tion of  varying  amounts  of  fluid  up  to  21  ounces,  we  get  an 
elevation  from  zero  up  to  nearly  2h  inches.  But  there  is  no 
constancy.  Thus,  two  males  of  34  and  35  respectively  after  an 
injection  of  10  ounces  into  the  bladder  give  elevations  off  inch 
and  if  inches  respectively.  One  male  of  30  with  15  ounces  in 
the  bladder  gives  an  elevation  of  i\^  inches;  while  another, 
aged  35,  with  16  ounces  gives  an  elevation  of  2f  inches. 
Petersen's  table  I  confess  I  cannot  understand.  Thus,  with 
21  ounces  of  fluid  in  the  bladder,  one  patient  has  the  supra- 
*  Med.-Chiy.  Trans,,  1886,  p.  354. 


666  SUPRA-PUBIC  CYSTOTOMY. 

pubic  fold  one  finger's  breadth  heloiv  the  pubic  margin,  while 
another  has  it  i^  inches  above.  There  is  no  use  in  striking  an 
average  between  extremes  such  as  these,  when  we  are  told 
nothing  about  the  anatomical  conditions.  In  fact,  according 
to  Petersen,  the  chances  are  about  even  that  a  pint  of  fluid  in 
the  bladder  will  not  raise  the  peritoneal  fold  at  all.  (In  ten  cases 
the  elevations  in  inches  are:  .33,  1.49,  o,  o,  .669,  .29,  —  .66, 
.39,  o,  .6.)  Until  these  observatious  are  confirmed  by  others 
I  cannot  accept  the  validity  of  Petersen's  results,  more  especially 
as  they  contradict  the  clinical  and  operative  experience  of  many 
years  and  many  men. 

A.  B.  Strong'*  of  Chicago  has  made  special  experiments  on 
this  point  with  the  same  object  as  those  of  Petersen,  Garson, 
and  Fehleison.  A  study  of  Strong's  results  serves  to  further 
confirm  the  validity  of  my  arguments. 

One  criticism  must  be  made  on  Strong's  paper.  In  Plate  I. 
of  it,  he  places  the  peritoneal  reflexion  at  the  level  of  the  middle 
of  the  symphysis,  a  position  described  in  the  text  as  "  one  and 
a  half  inches  below  the  crest  of  the  symphysis  pubis."  In  plate 
II.  the  peritoneal  reflexion  is  at  the  junction  of  the  upper  and 
middle  thirds  of  the  section  through  the  symphysis,  and  this 
position  is  described  in  the  text  as  "  one  inch  below  the  crest 
of  the  symphysis  pubis."  These  statements  are  in  harmony 
with  other  measurements  given  in  the  paper.  Now  these 
measurements  are  either  erroneous,  or  the  depth  of  the  sym- 
physis must  be  estimated  at  three  inches — an  estimate  which  is 
manifestly  excessive. 

Strong's  experiments  clearly  showed  that  "distension  of  the 
rectum  alone  elevates  the  base  of  the  empty  bladder,  but  does 
not  raise  materially  the  vesico-abdominal  fold  of  peritoneum." 
A  bladder  distended  with  fluid  tended  to  fall  backwards  into  the 
pelvis ;  and  he  found  that  distension  with  air  had  a  more  potent 
influence  in  elevating  the  peritoneal  fold.  This  is  an  obser- 
vation full  of  significance.  I  suspect  its  true  interpretation  is 
to  be  found  in  the  absence  of  all  muscular  influence  in  post- 
mortem experiments.  It  is  scarcely  credible  that,  in  the  living 
*  Annals  of  Surgery,  Jan.,   1887. 


SURGICAL   ANATOMY.  667 

subject  with  normal  abdominal  pressure  and  contracting  vesical 
and  parietal  muscle,  the  mere  presence  of  gas,  as  compared 
with  an  equal  amount  of  fluid  in  the  bladder,  should  influence  an 
anatomical  displacement.  It  is  surely  more  likely  that  the  dif- 
ference of  conditions  in  the  living  and  the  dead  must  explain 
this  difference.  Strong  considers  that  the  operation  is  simplified 
by  crowding  the  bladder  against  the  abdominal  wall  by  means 
of  distension  of  the  rectum,  and  considers  that  from  lo  to  12 
ounces  in  the  rectal  bag,  and  8  to  10  in  the  bladder,  are  the  best 
quantities  of  fluid  to  use.  In  his  cases  an  average  of  14  ounces 
in  the  rectum  and  12  in  the  bladder  elevated  the  peritoneal  fold 
an  average  of  1^  inches  above  the  crest  of  the  pubes.  Com- 
paring Kelrauth's  experiments  with  Strong's,  we  may  note  that 
in  25  cases,  with  an  average  quantity  of  water  in  the  bladder  of 
27  ounces  and  no  rectal  distension,  the  fold  was  raised  2  inches. 

One  observation  of  Strong's  I  must  heartily  endorse,  and  that 
is  the  wisdom  of  using  thin  rubber  for  the  rectal  bag.  A  thin 
bag  follows  up  the  gut  in  its  windings  ;  it  tends  to  straighten  it 
between  the  anus  and  the  sacral  promontory;  and,  he  might 
have  added,  it  cannot  burst  the  bowel,  while  it  utilises  to  the 
full  any  special  distensibility  which  the  rectum  may  possess. 

A  careful  stud}^  of  these  post-mortem  experiments  almost 
forces  one  to  the  conclusion  that  they  are  not  to  be  entirely 
trusted  as  guides  in  performing  the  operation  on  the  living  sub- 
ject, and  that  we  must  ultimately  depend  on  the  carefully 
recorded  experience  of  practical  surgeons. 

I  think  it  will  be  within  the  truth  if  we  assume  that,  in  an 
adult  male,  an  injection  of  from  15  to  20  ounces  of  fluid  will 
elevate  the  peritoneal  fold  at  least  one  inch  above  the  upper 
pubic  margin,  probably  nearly  two  inches,  and  possibl}^  over 
two  inches. 

The  influence  of  distension  of  the  rectum  in  adding  to  the 
elevation  of  peritoneum  caused  by  distension  of  the  bladder  has 
been,  in  my  opinion,  much  exaggerated.  Petersen's  table  I 
cannot  believe  to  be  trustworthy,  for  reasons  already  stated ; 
but  even  giving  him  the  status  of  a  special  pleader  in  favour  of 
distension  of  the  rectum,  we  find  that  the  average  increase  of 


668 


SUPRA-PUBIC  CYSTOTOMY. 


elevation  is  a  fraction  of  an  inch.  Supposing  14  ounces  are  in 
the  bladder,  and  21  ounces  are  injected  into  the  rectal  bag,  we 
find  elevations  given  of  i,  1.4,  .23,  .23,  .83,  .59,  .29,  .57,  .24,  .7 
inches.  Garson's  table  is  even  less  satisfactory ;  ]  Barwell's 
table  shows  that  the  elevation  is  ver)^  slight,  and  not  such 
*'  as  would  be  of  any  value  to  the  operator."  Theoretical!}', 
I  have  failed  to  understand  why  distension  of  the  rectum 
should  cause  much  elevation  of  the  peritoneal  fold.  A  blad- 
der distended  by  fluid-pressure  from  the  inside  naturally 
assumes  the  globular  shape ;  and  this  globular  shape  neces- 
sitates, for  anatomical  reasons,  elevation  of  the  peritoneal 
fold.  Supposing  this  globe  is  compressed  between  the  rectal 
bag  behind  and  the  parietes  in  front,  the  first  thing  that 
happens  is  that  it  is  flattened  against  the  parietes;  and  this 
flattening  can 
take  place  just 
as  easily  over  the 
folded  perito- 
neum as  by  bur- 
rowing under  it. 
There  is  no 
physical  neces- 
sity why  flatten- 
ing of  the  bladder 
should  elevate 
the  peritoneal 
fold ;  only  gen- 
eral increase  of 
its  dimensions 
will  do  this.  And 
practically,  my 
own  experience, 
as  well  as  that  of 
a  few  others,  is, 
that  if  rectal  dis- 
tension does  ele- 
vate  the  perito- 


FlG.   79.      (C.  Langer.) 

Sagittal  Median  Section  through  the  Pelvis  of  a  Young 
Man,  the  Bladder  being  Contracted. 


SURGICAL   ANATOMY. 


669 


neum,  it  is  to  an  unimportant  extent.  One  thing  rectal  distension 
will  do,  and  that  is,  to  push  forwards  the  posterior  wall  of  the 
bladder  :  in  the  removal  of  tumours  this  displacement  is  of  great 
value.  It  may  also  aid  the  operation  by  causing  the  full  bladder 
to  rise  well  forward  under  the  parietal  opening.  For  the  pur- 
pose of  elevating  the  peritoneum  I  am  convinced  that  it  is  of 
little  value. 

A  comparison  of  the  accompanying  engravings  will  bear  out 
my  argument.    Figs.  79  and  80,  from  drawings  of  frozen  sections, 

by  Langer, 
show  the  re- 
lations of  the 
bladder  to 
the  parietes 
when  the  or- 
gan is  con- 
tracted and 
when  it  is 
distended. 
Fig.  81  is 
reduced  by 
photography 
from  a  plate 
of  Garson's 
to  the  same 
scale  as  Lan- 
ger's,  and 
shows  the 
effects  of 
combined 
rectal  and 
vesical  dis- 
tension. It  will  be  seen  that  the  supra-pubic  interval  is  prac- 
tically as  large  after  simple  vesical  distension  as  after  combined 
rectal  and  vesical  distension.  On  the  other  hand,  the  base 
of  the  bladder  is  pushed  forward  by  the  rectal  bag,  and  the 
neck  of  the  bladder  is  greatly  elevated  from  its  natural  position 


(C.  Langer.) 

Sagittal  Median  Section  through  the  Pelvis  of  a  Young 
Man,  the  Bladder  being  Distended. 


670 


SUPRA-PUBIC  CYSTOTOMY. 


under  the  symphysis.  Flattening  of  the  bladder  over  the  folded 
peritoneum  without  elevation  of  that  membrane  is  also  well  shown 
in  Fig.  8i. 

The  structure  of  the  bladder-wall  is  well  known,  and  need 
not  be  dwelt  upon.  In  operating,  it  must  not  be  forgotten  that 
the  fibres  of  the  external  muscular  coat  arise  in  front  from  the 
posterior  surface  of  the  body  of  the  pubes,  and  may  easily  be 

torn  from  their 
insertion  by 
rough  manipula- 
tion. Two  large 
veins,  continua- 
tionsof  the  dorsal 
veinsofthepenis, 
pass  through  this 
insertion,  one  at 
each  side  of  the 
symphysis,  about 
three-quarters  of 
an  inch  apart ;  if 
the  knife  is  not 
kept  carefully  in 
the  middle  line, 
one  of  these  may 
be  wounded.  The 
three  muscular 
layers  —  external 
longitudinal, 
middle  circular, 
and  internal  lon- 
gitudinal —  form 
the  bulk  of  the  bladder-wall.  The  submucosa  is  intimately 
united  to  the  mucous  coat ;  the  mucous  coat  is,  by  comparison 
with  that  of  the  intestines,  thin  and  anaemic.  In  some  cases 
of  old-standing  calculus,  however,  it  becomes  greatly  thickened, 
with  the  submucosa. 


Fig.  8i.     (Garson.) 

Sagittal  Median  Section  of  Male  Pelvis,  ivith  Distention 
of  Bladder  and  Rectum. 


MORTALITY.  671 


MORTALITY    AND     APPRECIATION. 

The  early  mortalit}^  of  the  operation  in  the  hands  of  those 
who  studied  its  methods  was  under  15  per  cent,  for  all  cases, 
and  some  of  these  cases  were  very  bad  indeed.  Dulles,*  up  to 
1875,  ^^^*^  collected  records  of  478  cases.  An  analysis  of  these 
cases  showed  that  the  results  of  supra-pubic  lithotomy  were 
as  good  as  the  lateral  operation  for  calculi  weighing  between 
one  and  two  ounces,  and  better  for  calculi  weighing  above 
two  ounces.  In  1881  his  collection  of  cases  amounted  to  636, 
and  the  results  continued  unchanged.  Dennis's  collection  of 
127  cases  operated  on  since  1879  gives  a  mortality  of  9  per  cent. 
It  must  not  be  forgotten  that  these  cases  include  the  very  worst 
examples  of  stone.  Dr.  Ussendelft  of  Nijni-Novgorod  t  who, 
since  1883,  has  performed  exclusively  the  high  operation,  has 
had  102  operations  with  two  deaths,  one  being  left  with  fistula 
and  one  with  pyelitis.  He  had  no  fewer  than  20  cases  of 
primary  healing. 

At  the  present  day  the  operation  is  chiefly  coniined  to  cases 
of  very  large  stones,  and  to  young  children.  To  strike  an 
average  between  these  classes  of  cases,  and  draw  conclusions 
therefrom  as  to  the  general  mortality  of  the  operation,  is  absurd. 
For  children  the  cases  are  as  yet  too  few  to  be  entered  in  com- 
petition with  other  operations.  Most  surgeons  who  have  had 
experience  of  the  operation  prefer  it  to  all  others,  and  many 
regard  it  as  the  only  cutting  operation  which  should  be  per- 
formed on  the  bladder.  The  operation  is  at  present  on  the  crest 
of  a  wave  of  popularity,  and  is  perhaps  just  a  little  over-praised. 
Some  maintain  that  it  is  much  easier  to  perform  than  perineal 
C3'stotomy :  this  is  a  matter  of  opinion  and  of  experience ;  it  is 
certainly  not,  as  compared  with  manj'  other  operations,  difficult. 
Special  consideration  as  to  its  value  in  saving  life,  and  not 
interfering  with  subsequent  comfort,  has  been  given  under 
"  Indications  for  Operation,"  and  need  not  here  be  repeated. 
The  whole  question  may  be  summed  up  in  the  conclusion  formu- 

*  Amer.  Journ.  Med.  Sc,  July,  1875. 
t  Abstract  from  Vratcli,  St.  Petersburg,  in  Annals  of  Surgery,  May,  1S89. 


672  SUPRA-PUBIC  CYSTOTOMY. 

lated  by  Dulles,  whose  words  must  carry  great  weight :  "  I  have 
come  to  the  conclusion  that  a  temperate  view  of  the  subject  will 
lead  to  the  conviction  that  the  supra-pubic  operation  deserves 
to  rank  above  all  other  methods  of  lithotomy  for  stones  of  large 
size,  and  that  its  applicability  to  any  case  should  be  carefully 
discussed  before  deciding  to  cut  through  the  perineum." 


THE    OPERATION. 

Preparatory. — The  patient's  bowels  must  be  well  opened,  and 
the  rectum  cleared  by  enema  immediately  before  operation. 
Pubic  hair  must  be  shaved  off,  and  the  skin  in  the  neighbour- 
hood thoroughly  purified.  The  patient  is  laid  on  an  operating 
table  in  the  supine  position,  and  the  operator  and  his  assistant 
stand  on  the  right  and  left  of  the  patient,  as  in  an  ordinary  ab- 
dominal section.  The  steam  spray  is  not  essential,  as  the  cavity 
of  the  bladder  can  rarely  be  rendered  aseptic  ;  but  in  young 
children,  and  in  cases  of  papilloma  with  healthy  or  only  blood- 
mingled  urine,  the  spray  may  conduce  to  an  ideally  aseptic 
course. 

The  coverings  of  the  patient  should  be  so  arranged  that  the 
thighs  may  be  separated  and  access  given  to  the  rectum  without 
uncovering  any  part  of  the  body.  A  blanket  rolled  round  each 
limb,  and  a  third  over  the  chest  and  abdomen,  will  be  found 
efficient.  A  small  table  for  setting  irrigating  reservoirs  upon 
should  be  placed  near  the  foot  of  the  operating  table.  A  box, 
or  small  chair,  or  other  simple  piece  of  furniture  placed  on  this 
table,  will  serve  to  place  the  reservoirs  upon  when  it  is  desired 
to  raise  them  three  or  four  feet  above  the  level  of  the  patient. 

Instruments. — The  instruments  requisite  are  few  and  simple. 
A  sharp  scalpel,  a  pair  of  scissors,  a  sharp-pointed  tenaculum, 
and  half  a  dozen  pairs  of  catch-forceps,  with  the  apparatus  for 
distending  bladder  and  rectum  (if  necessary),  will  suffice  for  the 
performance  of  most  operations.  For  the  extraction  of  calculi, 
lithotomy  forceps  and  scoops ;  and  for  the  removal  of  tumours, 
curettes,  or   scrapers,   or  bent  forceps,  will  complete  the  list. 


DISTENSION   OF  THE  BLADDER.  673 

Some  surgeons  recommend  the  use  of  special  instruments :  Sir 
H.  Thompson,  for  instance,  uses  an  "ivory  separator"  and  a 
director,  and  for  special  conditions  a  hollow  sound  with  a  bul- 
bous stilet ;  but  none  of  these  instruments  are  essential. 

Distension  of  the  Bladder. — This  will  usually  be  the  first  step  of 
the  operation.  If  the  rectal  bag  is  to  be  used,  it  may  be  inserted 
as  the  first  part  of  the  operation ;  but  I  think  it  should  not  be 
filled  till  the  parietes  are  divided.  It  is  an  advantage  to  make 
the  dissection  with  the  fascia  and  cellular  tissue  as  lax  as  pos- 
sible ;  the  rectal  bag  crowds  forward  the  neck  of  the  bladder  and 
compresses  the  tissue  against  the  abdominal  wall,  so  that  vessels 
are  not  easily  seen  and  layers  are  not  easily  recognised.  The 
employment  of  the  rectal  bag  for  cases  of  calculus  is  of  doubt- 
ful utility.  For  bringing  up  the  posterior  wall  in  the  removal 
of  tumours,  the  rectal  bag  is  valuable.  But  it  cannot  do  this 
efficiently  till  the  bladder  is  opened,  at  least  not  while  there  is 
vesical  distension. 

Distension  by  hydrostatic  pressure  is,  in  my  opinion,  far 
superior  to  distension  by  hand  pressure  ;  and  for  these  reasons  : 

(i)  We  know  exactly  what  amount  of  pressure  we  are  putting 
on  the  vesical  walls.  An  elevation  of  three  feet  above  the  bladder 
is  about  one-twelfth  of  an  atmosphere,  or  a  little  over  a  pound 
to  the  square  inch ;  of  two  feet,  one-eighteenth  of  an  atmo- 
sphere, or  about  twelve  ounces ;  and  so  on.  Now,  the  amount 
of  fluid  injected  is,  for  a  diseased  bladder,  absolutely  no  criterion 
of  safet3^  In  many  cases  of  large  stone  the  bladder  is  enor- 
mously thickened  at  some  parts,  and  almost  ulcerated  through 
at  others,  while  it  is  frequently  tightly  closed  around  the  stone. 
To  force  eight  or  ten,  or  even  fourteen,  ounces,  as  is  often  recom- 
mended, into  such  a  bladder,  is  full  of  risk,  and  should  never  be 
done.  In  a  case  such  as  this,  an  elevation  of  two  feet  above 
the  bladder  would  be  safe ;  if  this  amount  of  pressure  will  not 
distend  it,  then  it  should  be  left  undistended. 

(2)  The  distending  force  is  applied  with  perfect  continuity, 
and  with  any  degree  of  rapidity  required.  Hand  pressure  is 
bound  to  be  irregular  and  intermittent ;  and  if  the  injection  is 

44 


674  SUPRA-PUBIC  CYSTOTOMY. 

made  as  a  part  of  and  during  the  operation,  it  will  almost  cer- 
tainly be  given  too  rapidly.  If  the  reservoir  is  placed  at  a  height 
of  two  or  three  feet  above  the  bladder  before  the  surgeon  begins 
to  make  the  first  incision,  a  gentle,  steady,  distending  force,  not 
unlike  that  naturally  produced  by  the  ureters,  but  more  rapid, 
will  be  gradually  filling  the  bladder. 

(3)  The  pressure  can  be  removed  instantaneously  simply  by 
lowering  the  reservoir  to  the  level  of  the  bladder,  and  increased 
to  any  extent  simply  by  elevating  it.  There  is  no  time  wasted 
in  adjusting  or  removing  the  syringe.  The  apparatus  is  always 
ready ;  and  by  the  simple  proceeding  of  elevating  or  depressing 
the  reservoir,  without  attaching  or  detaching  apparatus,  can 
either  empty  the  bladder  or  fill  it  to  distension. 

The  way  in  which  I  now  carry  out  distension  of  the  bladder 
is  as  follows  :  a  soft  rubber  catheter,  English  make,  of  size  as 
large  as  the  urethra  will  admit,  is  passed  into  the  bladder,  and 
any  urine  present  is  withdrawn.  The  tube  of  the  irrigator  is 
then  placed  over  the  end  of  the  catheter,  and  after  a  few  ounces 
of  boro-glyceride  solution  have  trickled  in  it  is  removed,  and  the 
fluid  permitted  to  run  into  a  receiver.  If  the  urine  is  very  foul, 
this  may  be  done  again  once  or  twice.  The  reservoir  connected 
with  the  catheter  is  then  placed  permanently  on  its  stand,  three 
feet  or  so  above  the  level  of  the  patient,  and  left  there  gradually 
to  distend  the  bladder  while  the  cutting  operation  is  going  on. 
An  elevation  of  three  feet  will  be  found  enough  for  children ;  for 
adults  with  thicker  and  less  distensile  bladder-walls,  four  feet 
will  be  the  upward  limit  of  safety. 

Any  form  of  reservoir  or  fountain  syringe  that  will  stand  is 
suitable.  It  is  convenient  to  have  it  fitted  with  a  glass  tube  as 
a  gauge  outside,  marked  in  ounces,  to  indicate  the  amount  of 
fluid  that  has  escaped  into  the  bladder.  It  ought  to  contain, 
at  least,  two  quarts,  in  order  that  it  may  be  used  for  washing 
out  the  bladder  after  operations. 

The  bladder  is  kept  distended  by  the  elevated  column  of 
fluid.  The  catheter  is  not  removed  ;  if  of  full  size,  no  fluid  will 
escape  by  its  side.  The  somewhat  barbarous  proceeding  of  tying 
the  penis  with  an  elastic  cord,  so  as  to  prevent  escape  of  the  fluid, 


DISTENSION   OF  THE  RECTUM.  675 

is  thus  done  away  with.  Should  the  patient  strain  much,  and 
the  abdominal  pressure  be  increased,  the  iluid  is  squeezed  out  of 
the  bladder  into  the  reservoir ;  it  is  better  that  this  should  take 
place  than  that  the  bladder  should  be  overstrained,  or  even 
ruptured.  When  the  straining  ceases,  the  fluid  will  pass  in 
again. 

The  rubber  tubing  which  joins  the  reservoir  to  the  catheter 
should  be  at  least  six  feet  in  length,  and  should  be  fitted  with  a 
stop  cock,  or  similar  contrivance,  to  check  the  flow  when  this 
is  necessary,  as,  for  instance,  when  the  bladder  is  opened. 

The  lotion  employed  should  be  of  the  warmth  of  the  body. 
No  antiseptic  for  employment  in  the  bladder  is  superior  to  boro- 
glyceride  ;  and  it  may  be  used  of  considerable  strength.  A  full 
tablespoonful  of  boro-glyceirde  to  the  quart  of  water  is  by  no 
means  too  strong.  The  soft  catheter  attached  to  the  irrigator 
need  not  be  removed  during  the  whole  operation.  It  can 
scarcely  be  in  the  way,  and  it  is  useful  for  conducting  fluid  into 
the  bladder  for  a  final  washing  out,  and  also  for  testing  the 
securit}^  of  the  bladder-suture  should  this  be  inserted.  Finally, 
if  it  is  considered  advisable  to  keep  the  bladder  empty  for  some 
time,  the  catheter  need  not  be  removed  at  all,  but  may  be 
tied  in. 

Nothing  is  said  as  to  the  amount  of  water  to  be  injected. 
The  capacity  of  the  bladder  is  not  to  be  measured  by  amount  of 
fluid,  but  by  its  distensibility  within  limits  of  safety.  Five  or 
six  ounces  of  injection  might  be  dangerous  in  a  bladder  greatly 
contracted,  and  perhaps  ulcerated,  as  in  cases  of  large  calculus: 
while  a  full  pint  might  easily  be  borne  in  such  a  case  as  one  of 
simple  papilloma.  The  only  safe  criterion  of  measurement  is 
that  of  force  of  distention ;  and  this,  I  maintain,  cannot  be 
estimated  accurately  by  the  hand,  but  it  can  undoubtedly  be 
measured  by  the  means  described. 

Distension  of  the  Rectum. — The  ordinary  rectal  bag,  as  supplied 
"  by  the  trade,"  is  a  formidable  looking  affair.  It  is  strong  enough 
to  cause  rupture  of  the  walls  of  the  rectum  (as  indeed  has  been 
proved  too  often),  and  when  rolled  up  to  its  smallest  dimensions 

44  * 


676  SUPRA-PUBIC   CYSTOTOMY. 

it  is  larger  than  the  largest  rectal  bougie.  Rectal  bags  are  now 
made  in  which  the  danger  of  over-distension  is  avoided  by  the 
use  of  silk  webbing  incorporated  with  the  rubber.  But  the 
avoidance  of  this  risk  may  be  attended  with  a  disadvantage,  in 
not  having  the  rectum  distended  to  its  full  capacity.  The  dis- 
tensibility  of  the  rectum  varies  greatly  in  individuals:  the 
protected  rubber  bag,  while  safe  for  a  small  rectum,  does  not 
utilise  to  the  full  the  distensibility  of  a  large  one.  I  should 
discard  the  rectal  bag  in  common  use  absolutel}',  and  use 
instead  a  more  delicate  apparatus.  A  child's  air-balloon  or 
a  delicate  soft  rubber  urinal,  fitted  on  to  a  celluloid  catheter, 
answers  the  purpose  admirably.  While  strong  enough  for  the 
purpose  intended,  it  is  not  strong  enough  to  rupture  the  gut. 
It  must  be  remembered  that  the  chief  virtue  of  the  rectal  bag  is, 
not  to  increase  the  supra-pubic  interval,  but  to  bring  the 
posterior  wall  of  the  bladder  up  into  the  wound.  As  usually 
employed  the  rectal  and  vesical  bags  are  little  else  than  two 
fluid  globes  mutually  undergoing  a  compressing  and  flattening 
process  between  the  parietes  and  the  sacrum.  The  rectal  bag 
can  scarcely  bring  the  bladder-wall  forwards  till  the  bladder  is 
opetied ;  then  it  does  so  with  ease  and  without  the  obstacle  of  a 
globe  of  fluid  under  high  pressure.  For  this  purpose  the  air- 
balloon  is  quite  strong  enough  ;  and  its  use  is  attended  with  no 
danger,  for  it  will  give  way  (as  I  have  ascertained)  before  the 
rectum  will. 

The  balloon,  fitted  to  the  catheter,  is  greased  (oil  injvu'es  the 
rubber  tissue)  and  introduced  well  into  the  rectum.  The  end  of 
the  catheter  is  attached  to  the  rubber  tubing  coming  from  a 
reservoir  similar  to  that  for  the  bladder.  A  pint  of  fluid  in  the 
reservoir  will  usualh^  be  found  sufficient.  Distension  is  produced 
in  the  same  way  as  for  the  bladder  simply  by  elevating  the 
reservoir  two  or  three  feet.  When  the  bladder  is  opened,  and 
while  the  tumour  is  being  explored  with  the  finger,  the  reservoir, 
already  placed  on  the  elevated  stand,  is  connected  with  the 
rectal  bag  by  removing  the  clamp  from  the  rubber  tubing :  dis- 
tension to  the  necessary  extent  takes  place  in  a  minute  or  two. 

It  is  no  small  recommendation  of  this  method  of  distending 


PARIETAL   INCISION.  677 

bladder  and  rectum  that  it  may  be  carried  out  from  beginning  to 
end,  not  only  without  any  interference  at  the  hands  of  the  surgeon 
(beyond  insertion  of  catheter  and  bag),  but  even  while  he  is 
actually  engaged  in  the  cutting  part  of  the  operation.  The  tubes 
from  the  reservoir  being  attached  to  the  catheters  in  bladder 
and  in  rectum,  the  bladder  reservoir  is  elevated  and  he  proceeds 
at  once  to  make  the  parietal  incision.  By  the  time  this  is 
finished,  and  before  the  bladder  is  exposed,  distension  will  have 
been  completed.  Should  extra  distension  seem  desirable,  this 
can  at  once  be  supplied  by  an  assistant  or  nurse  raising  the 
reservoir  a  little  higher. 

The  Incision  through  the  Parietes. — A  vertical  incision  from  twc> 
to  three  inches  in  length,  according  to  the  size  of  the  patient,  is 
made  exactly  in  the  middle  line  over  the  pubes.  The  lower  end 
of  the  incision  should  pass  below  the  upper  border  of  the  sym- 
physis for  a  distance  of  at  least  a  third  of  an  inch.  The  thick 
fascia  forming  the  linea  alba  being  exposed,  a  small  transverse 
incision  is  made  through  it  close  to  the  symphysis.  This  inci- 
sion is  made  transversely  partly  because  it  is  the  easiest  and 
safest  way  of  dividing  the  fascia,  and  partly  because  it  at  once 
exposes  the  actual  division  between  the  two  recti,  but  chiefly 
because  it  opens  up  the  field  of  operation,  which  is  often  cramped 
by  the  strong,  tense  and  closely  set  fibres.  Through  this  trans- 
verse opening  the  point  of  the  scalpel  (or  scissors)  is  insinuated, 
and  the  fascia  divided  upwards  in  the  middle  line  to  the  top  of 
the  wound,  the  edge  of  the  knife  being  directed  forwards.  The 
recti  are  now  separated,  and  the  transversalis  fascia  appears,  and 
is  divided  as  in  abdominal  section.  At  this  stage  one  is  usually 
struck  by  the  great  power  of  these  muscles,  and  how  vigorously 
they  resist  separation,  even  when  the  patient  is  fully  an^s- 
thetised.  If  their  tension  is  so  great  as  to  hamper  subsequent 
proceedings,  part  of  their  insertion  into  the  pubic  bones  should 
at  once  be  divided.  This  greatly  increases  the  space.  For 
the  purpose  of  keeping  the  recti  apart,  I  have  devised  strong 
wire  retractors  (Fig.  82),  of  different  sizes,  so  shaped  that  they 
will  retain  their  position  when  placed.    One  end  of  the  retractor 


678 


SUPRA-PUBIC   CYSTOTOMY. 


Fig.  82. 

Retractor  for  Supra-Pubic  Cystotomy. 


(the  ends  are  of  different  sizes)  is  placed  longitudinally  in  the 
vertical  opening  between  the  muscles;  it  is  then  rotated  through 
quarter  of  a  circle,  so  that  its  free  end  is  over  the  pubes.  By 
this  afction  the  recti  are  separated,  the  retractor  is  then  pulled 
down  towards  the  symphysis  to  be  out  of  the  way,  and  in  this 
position  it  will  remain  without  any  attention.  This  instrument 
is  very  useful  when  consider- 
able space  is  wanted  by 
keeping  apart  the  recti  and 
opening  up  the  field  of  oper- 
ation :  usually,  however,  it 
will  not  be  required. 

When  the  transversalis 
fascia  is  divided,  or  rather 
the  anterior  layer  of  fascia 
which  is  continued  downwards  from  the  fold  of  Douglas,  the 
3'ellow  peri-vesical  fat  comes  into  view.  The  scalpel  is  now 
laid  aside,  and  the  forefinger,  keeping  close  to  the  symphysis, 
and  undermining  it  so  to  speak,  teases  apart  the  fat  with  the 
numerous  vessels,  mostly  large  veins,  which  lie  in  it.  At  this 
stage,  while  the  pulp  of  the  forefinger  rests  on  the  bladder- 
wall,  the  distension  reservoir  is  elevated  a  foot  or  two  higher, 
and  the  bladder  is  felt  steadily  to  expand  and  to  become  more 
tense.  While  this  is  being  done,  the  finger  may  sometimes  feel 
the  peritoneal  fold  gliding  upwards  quite  plainly.  The  fingers 
during  this  process  of  final  distension,  aided,  perhaps,  by  catch- 
forceps,  will  have  teased  the  fatty  and  cellular  tissue  aside,  and 
thoroughly  exposed  the  wall  of  the  bladder.  Much  of  the  tissue 
should  be  pushed  upwards,  carrying  the  peritoneum  in  front  of 
it,  and  acting  as  padding  and  protection  to  that  membrane. 
While  the  bladder-wall  is  gradually  becoming  more  tense,  and 
rising  upwards,  and  the  finger  is  teasing  an  opening  in  the 
fibrous  tissue,  the  sense  of  touch  somehow  carries  to  the  mind 
an  impression  of  security,  or  rather  of  certainty,  as  to  the  positive 
limits  of  vesical  tissue  proper.  Fat,  fibrous  tissue,  and  peri- 
toneum may  be  moved  about  anywhere,  but  the  bladder- wall 
itself  remains  stable  and  increasingly  firm  under  all. 


OPENING   THE  BLADDER.  679 

When  a  sufficient  amount  of  bladder  surface  has  been 
cleared  we  proceed  at  once  to  the  next  step. 

Opening  the  Bladder. — Several  methods  of  making  the  opening 
into  the  bladder  are  in  vogue,  and  I  have  tried  most  of  them. 
In  several  cases,  I  have  employed  a  Lister's  sinus  forceps  for  the 
purpose,  first  gently  insinuating  it  through  the  outer  muscular 
coats,  and  then  sharply  pushing  it  into  the  cavity.  As  the 
blades  are  separated  the  opening  is  distended,  and  the  vesical 
wall  may  be  pulled  forward  into  the  wound.  I  found  that  the 
opening  so  made  was  liable  to  be  irregular  and  lacerated,  and 
not  suitable  for  subsequent  suturing.  A  good  many  surgeons 
begin  by  placing  thick  fixation  threads  of  silk  in  the  bladder  by 
curved  handled  needles,  and  make  the  division  by  knife  while 
the  bladder  is  pulled  forwards.  Besides  the  palpable  objection 
to  the  making  of  more  openings  in  the  bladder  than  are  necessary, 
there  is  another  objection  to  the  use  of  threads  in  the  tendency 
which  they  have  to  tear  the  vesical  tissue.  Several  other  plans 
have  been  mentioned  and  recommended,  but  the  best,  on  the 
whole,  is  probably  by  a  clean  incision  made  through  the  walls, 
which  are  held  forward  by  a  tenaculum.  The  tenaculum,  held  in 
the  left  hand,  is  pushed  sharply  through  the  coats,  its  entrance  into 
the  cavity  being  signalised  by  the  exit  of  a  few  drops  of  fluid  (if 
this  fluid  is  tinted  blue  with  litmus,  it  is  more  easily  seen),  and 
its  point  is  turned  upwards.  Immediately  below  the  tenaculum, 
into  the  same  opening  it  may  be,  the  point  of  a  sharp  scalpel, 
held  in  the  right  hand,  is  gently  insinuated,  and  the  opening 
made  by  a  steady  cut  downwards.  This  opening  will  var}^  in 
length  according  to  the  work  to  be  done  through  it :  at  first  it 
need  never  be  longer  than  an  inch ;  it  may  be  extended  after- 
wards. It  must  not  be  forgotten,  however,  that  as  the  bladder 
empties,  the  peritoneal  fold  falls  downwards,  and  it  may  then  be 
difficult  and  dangerous  to  extend  the  opening  in  an  upward 
direction.  Therefore,  the  tenaculum  should  be  inserted  not 
lower  down  than  the  uppermost  limit  of  the  incision.  It  is 
sometimes  not  easy  to  define  this  limit.  In  a  thickened  and 
contracted    bladder,  which    is  not  safe  to  distend,  the    supra- 


680  SUPRA-PUBIC  CYSTOTOMY. 

pubic  interval  may  be  short  or  absent,  and  the  peritoneum  has 
to  be  undermined,  first  downwards  under  the  pubes  and  then 
upwards  over  the  bladder,  as  in  the  operation  for  tying  the 
external  iliac  artery.  In  such  a  case  the  urachus  may  often 
be  felt  as  a  round,  somewhat  tense  cord,  and  a  small  knob  repre- 
senting its  insertion  into  the  summit  of  the  bladder  is  occasion- 
ally perceptible.  Peritoneum  never  passes  the  urachus ;  it  is 
always  safe  to  go  as  high  as  this  point.  This  practical  hint, 
thrown  out  by  Thornhill  a  century  and  a  half  ago,  is  by  no  means 
to  be  despised  in  the  surgery  of  to-day. 

As  the  opening  is  made  the  fluid  flows  from  the  bladder,  and 
its  walls  collapse.  To  prevent  retraction  two  catch-forceps  are 
made  to  grasp  the  lips  of  the  wound,  and  the  tenaculum  is 
removed.  Loops  of  silk  inserted  by  a  needle  are  usually  em- 
ployed for  this  purpose ;  the  tendency  of  these  to  tear,  and  the 
formation  of  further  openings  in  the  bladder,  are  objections  to 
the  use  of  threads.  At  first  I  was  afraid  that  the  pressure  ex- 
erted by  the  blades  of  the  forceps  might  cause  sloughing.  True, 
proof  against  this  is  abundantly  afforded  in  the  fact  that  catch- 
forceps  are  constantly  being  left  hanging  to  pieces  of  tissue  for 
long  periods  without  endangering  their  vitality ;  and,  as  a  matter 
of  experience,  forceps  do  no  harm  whatever.  Compression  need 
not  be  employed  to  the  fullest  extent,  and  traction  must  be  no 
more  than  sufficient  to  keep  the  bladder  opening  upwards  in  the 
parietal  opening. 

Placing  the  forceps  is  very  quickly  done,  and  not  much  of 
the  fluid  will  in  the  meantime  have  escaped.  It  matters  very 
little,  however,  if  the  whole  has  escaped.  If,  as  can  seldom  be 
the  case,  it  is  desirable  to  explore  with  the  bladder  full,  the 
finger  can  at  once  plug  the  opening,  and  the  bladder  may 
be  refilled  simply  by  permitting  the  distending  apparatus  to 
work. 

Intra-vesical  Manipulations. — These  vary  according  to  the 
purpose  for  which  the  operation  is  performed  ;  namely,  removal 
of  a  stone,  a  foreign  body,  or  a  tumour,  or  the  hypertrophied 
prostate  gland. 


EXTRACTION   OF  CALCULUS.  681 

Extraction  of  Calculus. — The  extraction  of  a  calculus  by  the 
supra-pubic  route  is  usually  a  proceeding  of  the  simplest  possible 
nature.  If  the  rectal  bag  is  not  employed,  and  the  lips  of  the 
wound  in  the  bladder  are  held  forward  in  the  grasp  of  catch- 
forceps,  the  bladder  when  empty  will  form  a  simple  elongated 
sac,  at  the  bottom  of  which  the  stone  will  be  found. 

In  children,  where  the  stone  is  usually  small  and  the  bladder 
walls  lax  and  distensile,  extraction  may  be  performed  with  great 
ease.  Some  surgeons  recommend  the  employment  of  the 
fingers,  or  the  finger  with  a  scoop,  for  removing  the  stone ;  I 
should  advise  the  use  of  small  lithotomy  forceps.  The  finger  or 
fingers  quite  unnecessarily  add  to  the  dimensions  of  the  body  to 
be  extracted,  and  so  cause  needless  dilatation  or  tearing  of  the 
wound  in  the  bladder.  Forceps  of  proper  dimensions,  while 
quite  efficient  for  the  purpose,  do  not  add  to  the  bulk  of  the 
stone  so  much  as  the  fingers.  Nearly  always  the  stone  is  caught 
between  the  blades  at  the  first  trial,  without  the  insertion  of  the 
finger  at  all ;  if  there  is  any  difficulty  in  grasping  the  stone,  the 
finger  introduced  along  the  blades  may  place  the  stone  between 
them,  but  should  be  removed  before  the  stone.  In  view  of  the 
extreme  desirability  of  getting  union  of  the  vesical  wound  in 
children,  it  is  important  that  there  should  be  as  little  traumatism 
and  as  small  an  opening  as  possible.  The  rectal  bag  raises  the 
base  of  the  bladder  so  as  to  make  it  become  convex  towards  the 
the  front ;  the  stone  falls  off  this  convexity  into  some  part  of 
the  encircling  sulcus,  and  is  not  so  easily  found  as  when  the 
bladder  remains  as  a  simple  sac.  However,  in  very  few  cases 
can  the  finding  of  the  stone  be  difficult.  In  cases  of  real  diffi- 
culty, as  when  the  stone  is  encapsuled,  the  finger  in  the  rectum 
is  the  best  means  of  pushing  the  stone  out  of  its  bed. 

In  adults,  and  particularly  in  old  men,  the  stone  in  most  cases 
will  be  very  large,  the  bladder  walls  very  thick,  and  perhaps 
ulcerated,  and  the  situation  of  the  viscus  will  be  well  back  in 
the  hollow  of  the  sacrum.  Vesical  distension  to  any  great  ex- 
tent will  then  be  either  dangerous  or  impossible,  and  the  incision 
through  the  front  of  the  bladder  will  probably  at  once  expose  the 
stone.     It  is  then  a  question  of  how  to  remove  the  stone  through 


682  SUPRA-PUBIC   CYSTOTOMY. 

the  smallest  opening,  and  with  the  greatest  possible  delicacy. 
Towards  this  end,  one  or  two  fingers  in  the  rectum  are  more 
useful  than  the  rectal  bag.  One  or  two  fingers  of  the  right  hand 
in  the  rectum,  with  the  fingers  of  the  left  hand  through  the 
bladder  wound,  may,  by  judicious  and  careful  manipulation, 
disturb  the  stone  from  its  bed,  and  place  it  so  that  its  smallest 
diameter  lies  transversely  to  the  bladder  wound.  By  the  com- 
bined manipulation  the  stone  may  often  be  pushed  out  of  the 
bladder ;  if  manipulation  do  not  readily  succeed,  a  suitably 
shaped  lithotomy  forceps  may  be  made  to  grasp  it,  and  help  in 
the  extraction.  Force  must  not  be  employed ;  if  the  vesical 
walls  appear  to  be  stretched,  and  likely  to  tear  over  the  shoulders 
of  stone  or  forceps,  they  must  be  divided  by  a  scalpel  cutting 
down  on  the  stone  or  the  steel  to  what  extent  is  necessary.  In 
this  operation  there  is  no  excuse  whatever  for  the  production  of 
bruising  or  laceration.  If  the  stone  is  of  small  or  moderate 
size,  it  may  readily  be  removed  by  forceps  without  the  aid  of 
the  finger  in  the  rectum  or  in  the  bladder. 

Extraction  of  Foreign  Bodies. — Here  the  insertion  of  the  finger 
for  exploratory  purposes  is  always  advisable.  The  nature  of  the 
body,  and  the  possible  existence  of  ulceration  or  even  perfora- 
tion of  the  vesical  walls  by  sharp  points,  are  made  out. 
According  to  the  information  thus  conveyed  the  mode  of  removal 
is  decided  upon.  A  small,  blunt,  or  rounded  foreign  body  may 
easily  be  removed  by  forceps.  A  long  foreign  body  which  can- 
not easily  be  tilted  on  end  should,  if  possible,  be  divided.  In 
such  manipulations  we  must  always  bear  in  mind  the  possibility 
of  perforating  the  bladder,  and  proceed  with  extreme  circum- 
spection. If  actual  perforation  exists,  or  is  produced,  the 
parietal  incision  should  at  once  be  prolonged  upwards,  the 
peritoneal  cavity  opened,  and  the  wound  in  the  bladder  sutured 
in  the  manner  to  be  described  for  rupture  of  the  bladder. 

Removal  of  Tumours. — Most  tumours  may  be  removed  with 
the  instruments  provided  for  the  general  operation.  Medium- 
sized  Wells'  forceps,  with  blades  set  at  right  angles  to  the 
handles,  will  be  found  useful  for  grasping  pedunculated  tumours 
at  their  attachment  to  the  bladder,  and  for  twisting  them  off. 


REMOVAL   OF  TUMOURS.  685 

Volkmann's  spoons  or  ordinary  curettes  will  be  necessary  where 
scraping  is  emplo3^ed.  Sir  Henry  Thompson  invented  several 
special  forceps  for  removing  tumours  by  the  perineal  route : 
these  may  be  found  useful  in  the  hypogastric  operation.  The 
electric  light  introduced  into  the  bladder  may  be  useful  for 
examining  the  tumour  before  removal,  or  the  pedicle  after  it 
has  been  removed. 

Polypi  should  be  twisted  off.  A  bent  catch-forceps,  guided 
by  the  fingers  of  the  left  hand,  is  made  to  grasp  the  pedicle- 
close  to  its  attachment  to  the  bladder,  and  handed  over  to 
an  assistant.  A  second  similarly  shaped  forceps  is  placed  on 
the  growth  immediatel}^  above  the  first,  and  twisted  round,  while 
the  lower  forceps  is  held  stationary  xmtil  the  pedicle  is  twisted 
through.  Small  polypi  may  be  at  once  twisted  off  the  bladder. 
Large  polypi  are,  I  believe,  most  safely  removed  by  twisting 
between  two  pairs  of  forceps.  The  twisting  of  a  tumour  with 
considerable  attachments  to  the  vesical  walls  of  necessity  does 
considerable  injury  to  the  tissues,  and  may  result  in  ulceration 
or  sloughing  of  the  vesical  walls.  The  red-hot  galvanic  wire 
has  been  used  for  the  purpose  of  dividing  the  pedicle. 

Papillomata  with  pedicles  are  most  conveniently  removed 
by  twisting,  as  described  for  polypi.  Small,  very  soft  dendritic 
papillomata  are  best  removed  by  scraping  or  curetting  between 
a  suitable  instrument  and  the  forefinger.  Indeed,  the  finger- 
nail alone  will  suffice  for  the  detachment  of  many  of  these 
tumours.  Of  larger  size,  these  growths  must  be  attacked  with 
sharp  spoons  or  forceps,  like  the  "gouge"  bone-forceps  (which 
suits  admirably).  A  fibro-papilloma  is  detached  piecemeal  by 
scoops  or  curettes  guided  and  assisted  by  the  finger.  If  a 
pedicle  can  be  grasped,  it  may  be  twisted  off.  Epithelioma  can 
only  be  scraped  and  curetted  in  the  same  wa3\  Most  of  these 
tumours  lie  on  a  bed  of  hypertrophied  muscular  tissue,  so  that 
there  is  little  danger  of  perforating  the  vesical  walls  ;  still,  the 
finger  should  always  be  alongside  of  the  instrument,  to  make 
certain  that  it  does  not  advance  too  far. 

Detached  tumours  are  subsequently  removed  by  the  stream 
of  fluid  sent  into  the  bladder  through  the  irrigator.     It  unneces- 


684  SUPRA-PUBIC   CYSTOTOMY. 

sarily  adds  to  the  length  of  the  operation  and  the  traumatism  to 
remove  every  particle  from  the  cavity  as  it  is  detached. 

Bleeding  in  these  cases,  though  sometimes  free  at  the  moment, 
rarely  continues  over  any  length  of  time.  Should  it  continue, 
and  be  at  all  alarming,  a  careful  application  of  the  actual  cau- 
tery to  the  bleeding  area  through  a  small  cylindrical  speculum 
is  probably  the  most  effectual  and  least  harmful  mode  of  check- 
ing it.  Topical  application  of  powerful  astringents  may  set  up 
troublesome  cystitis. 

It  must  be  noted  that  benign  tumours  of  the  bladder  have  a 
tendency  to  return.  Recurrence  has  taken  place  in  at  least  one 
in  five  of  all  the  cases  operated  upon.  This  was  Guyon's  pro- 
portion in  15  cases  of  operation  ;  and  a  study  of  scattered  cases, 
including  those  of  Sir  Henry  Thompson,  shows  a  similar  pro- 
portion. Looking  at  the  condition  which  obtains  in  cases  of 
numerous  soft  scattered  polypi,  this  is  not  at  all  surprising ;  for 
many  of  these  tumours  must  be  imperceptible  to  the  sense  of 
touch,  or  even  microscopic.  Recurrence  in  these  cases  may  be 
a  continued  growth  of  the  undetected  tumours,  as  much  as  a 
renewed  growth  of  imperfectly  removed  ones.  Repeated  opera- 
tion may  then  result  in  perfect  cure.  In  the  larger  single  growths, 
recurrence  is  most  likely  a  sequence  of  imperfect  removal.  In 
the  case  of  epithelioma  that  is  scraped,  we  can  expect  nothing 
more  than  temporary  amelioration  of  symptoms.  In  one  such 
case  on  which  I  operated,  the  amount  of  relief  from  pain  and 
tenesmus  which  followed,  and  continued  for  nearly  six  months, 
surprised  all  concerned  in  the  treatment.  If  the  pain  and 
tenesmus  had  recurred,  the  patient  would  certainly  have 
requested  repetition  of  the  operation  :  death  took  place  from 
haemorrhage. 

In  the  case  of  malignant  tumours  involving  the  fundus,  the 
propriety  of  resection  would  have  to  be  considered.  This  will 
be  dealt  with  further  on. 

The  operation  of  partial  pvostatedomy  has  not  yet  been  fully 
elaborated.  In  McGill's  latest  description  of  his  operation, '■= 
three  distinct  varieties  of  prostatic  enlargement  are  described 
*  Luncet,  Feb.  4th,  1888. 


PROSTATECTOMY.  685 

as  being  possible  indications  for  operation.  The}^  have  all  one 
common  characteristic — "  they  are  all  growths  which  protrude 
into  the  bladder  cavity,  and  may  consequently  be  described  as 
vesical  and  not  as  perineal  outgrowths."  The  varieties  are — 
"  (i)  A  uniform  circular  projection  surrounding  the  internal 
orifice  of  the  urethra.  .  .  .  (2)  A  sessile  enlargement  of  the 
middle  lobe,  situated  partly  in  the  posterior  half  of  the  prostatic 
urethra  and  partly  in  the  position  of  the  uvula  vesicae.  .  .  . 
(3)  A  pedunculated  enlargement  of  the  middle  lobe." 

"  The  operation  consists  of  two  parts  :  (i)  The  opening  and 
drainage  of  the  bladder ;  and  (2)  the  removal  of  the  prostatic 
valve,  which  prevents  the  egress  of  urine."  For  the  fulfilment 
of  both  these  conditions  the  supra-pubic  operation  is  the  best. 
This  is  performed  in  the  way  described  above.  The  rectal  bag 
should  be  employed.  The  neck  of  the  bladder  and  the  region  of 
the  prostate  are  carefully  examined  by  the  finger,  and  the  actual 
variety  of  enlargement  diagnosed.  According  to  the  nature  of 
the  enlargement  we  adopt  measures  for  its  removal.  "A  pedun- 
culated middle  lobe  can  obviously  be  removed  with  ease,  its 
pedicle  being  divided  with  curved  scissors.  A  sessile  middle 
lobe  can  be  removed  iij  the  same  wa}-,  helping  the  scissors  by 
tearing  with  forceps.  The  collar  enlargement  is  removed  with 
greater  difficult3\  It  is,  I  think,  advisable  to  divide  it  longi- 
tudinally by  inserting  one  blade  of  the  scissors  into  the  urethral 
opening  and  dividing  the  portion  above,  and  then  passing  the 
other  blade  into  the  same  opening  and  dividing  the  portion 
below.  We  now^  have  that  part  of  the  gland  which  projects 
into  the  bladder  divided  into  two  lateral  halves  ;  these  can 
be  removed  separately  by  scissors  curved  on  the  flat,  or  enu- 
cleated with  the  tip  of  the  forefinger.  Care  must  be  taken  not 
to  leave  any  portion  of  the  projecting  valve  untouched.  When 
the  operation  is  completed,  whichever  form  of  growth  has  been 
removed,  it  is  advisable  to  see  that  the  urethra  is  patent,  and  to 
pass  the  forefinger,  as  far  as  the  first  joint,  into  its  canal." 
Haemorrhage  is  not  excessive,  and  may  easily  be  arrested  by 
the  injection  of  a  hot  antiseptic  solution.  The  bladder  is  drained 
by  a  rubber  tube  carried  out  through  the  lower  angle  of  the 


€86  SUPRA-PUBIC   CYSTOTOMY. 

wound,  which  is  removed  at  the  end  of  forty-eight  hours.  Four 
cases  treated  in  this  way  by  McGill  made  excellent  recoveries, 
and  were  completely  cured  of  their  troubles,  being  able  to  pass 
water  without  the  aid  of  the  catheter,  and  being  cured  of  the  con- 
dition of  purulent,  foetid,  and  alkaline  urine  ;  and  in  one  case  the 
patient  was  freed  from  symptoms  of  uraemia  and  surgical  kidney. 

When  intra-vesical  operations  are  concluded,  the  bladder  is 
washed  out  by  irrigation  through  the  catheter  still  lying  in  the 
urethra.  The  lotion  in  the  reservoir  will  by  this  time  have 
cooled  down,  and  a  sufficient  amount  of  hot  water  to  raise  it  to 
temperature  of  the  body  should  be  added.  As  the  lotion  flows 
out  through  the  hypogastric  wound  it  may  be  collected  either 
in  sponges  or  wet  cloths,  or  in  a  properly  shaped  vessel  held 
under  the  wound  while  the  patient  is  turned  a  little  on  one  side. 
Fragments  of  growth  and  pieces  of  blood-clot  are  washed  away 
in  the  stream.  Irrigation  may  be  stopped  when  the  lotion 
returns  as  clear  as  when  it  left  the  reservoir. 

Suturing  the  Wound  in  the  Bladder. — The  propriety  of  suturing 
the  bladder  wound  has  been  very  much  discussed.  Some 
surgeons  absolutely  condemn  the  proceeding  under  all  circum- 
stances ;  others  as  universally  recommend  it ;  while  a  third 
class  would  limit  its  application  to  suitable  cases  selected 
according  to  the  judgment  of  the  surgeon,  guided  by  the 
leading  principles  of  sound  surgery. 

It  is  unnecessary  to  follow  the  numerous  arguments  for  and 
against  the  operation  of  vesical  suture.*'  It  may  here  be 
remarked  that  many  of  the  condemnatory  arguments  are  based 
on  erroneous  and  imperfect  modes  of  suturing,  and  should  not 
prevail  against  well-devised  modes  ;  while  too  hasty  generalisa- 
tions in  favour  of  suture  in  general  are  based  upon  one  or  two 
successes  in  particular  instances. 

That  successful  suture  of  the  bladder,  followed  by  primary 

*  Those  desirous  of  pursuing  the  subject  will  find  it  exhaustively  handled 
by  Gross  of  Nancy  in  the  Memoires  clu  Cong/es  Francais  de  Chirurgie.  2e  Sess. 
Paris,  1886, 


SUTURE   OF  THE  BLADDER.  687 

union,  greatly  adds  to  the  comfort  of  the  patient  and  the 
rapidity  of  recovery  there  can  be  no  dispute.  And,  if  a  suffi- 
ciently large  number  of  cases  could  be  compared,  no  doubt  it 
could  be  shown  that  it  adds  to  the  chances  of  recovery  as  well. 
To  base  an  argument  (as  has  been  done)  in  favour  of  the  reduced 
mortality  after  suture  is  misleading ;  because  suture  has  been 
applied  chiefly  in  the  most  favourable  cases  and  in  children. 
On  the  other  hand,  although  it  would  be  difficult  to  prove  it, 
there  can  be  no  doubt  that  an  injudicious  application  of  the 
suture  adds  to  the  patient's  danger. 

In  speaking  of  the  indications  and  contra-indications  to  the 
employment  of  vesical  suture,  only  very  general  statements  can 
be  employed.  We  must  take  into  account  such  circumstances  as 
the  condition  as  to  health  or  disease  of  the  vesical  walls,  with 
respect  to  their  capacity  for  uniting  ;  the  condition  of  the  vesical 
mucous  membrane,  as  to  whether  it  is  likely  to  secrete  inflam- 
matory products ;  and  the  power  of  the  bladder-muscle  to 
contract  and  empty  the  viscus. 

In  more  than  one  case  primary  union  of  the  bladder  wound 
has  taken  place  without  the  employment  of  any  suture.  -■= 

In  cases  where  the  vesical  tissues  are  greatly  thickened  or 
inflamed  or  oedematous  or  gorged  with  blood,  no  attempt  at 
suture  should  be  made.  Such  an  attempt  will  almost  certainly 
fail  to  give  union,  and  will  unnecessarily  add  to  the  traumatism. 
In  other  cases,  chiefly  of  very  large  stone,  there  may  exist 
ulcers  or  abrasions  on  the  mucous  surface  in  the  region  of  the 
wound  :  here  also  suturing  is  not  likely  to  be  successful,  and 
may  aggravate  the  ulceration,  and  even  cause  sloughing.  If 
cystitis  has  existed  for  some  time,  and  we  apprehend  the  secre- 
tion of  muco-purulent  products  into  the  cavity  after  operation, 
suture  should  not  be  employed.  Drainage  is,  in  fact,  one  means 
of  treating  this  inflammation  ;  and  even  if  suture  were  successful, 
the  cure  of  the  inflammation  through  the  urethra  with  a  closed 
bladder  is  not  likely  to  be  so  rapid  as  through  the  bladder 
wound.  Finally,  if,  from  repeated  or  long-continued  over- 
distension or  inflammatory  infiltration,  the  vesical  muscle  has 
*  Amcr.  Pract.  and  News,  Feb.  i6,  1889. 


688  SUPRA-PUBIC    CYSTOTOMY. 

lost  its  tone,  and  cannot  completely  empty  the  viscus,  we  should 
hesitate  before  adopting  primary  suture.  Such  a  case  would 
be  where  there  is  excessive  haemorrhage,  and  the  bladder  is 
frequently  filled  to  distension  with  clotted  blood  which  cannot 
be  passed  in  the  urine.  Even  with  a  catheter  passed  through 
the  urethra  into  the  bladder,  residual  urine  collects,  and  will 
undergo  decomposition  and  cause  cystitis. 

On  the  other  hand,  given  a  case  in  which  the  tissues  in  the 
wall  of  the  bladder  are  healthy,  the  muscles  capable  of  con- 
tracting naturally,  and  the  mucous  membrane  not  likely  to 
secrete  inflammatory  or  noxious  products,  then  we  may  suture 
the  bladder  wound.  The  great  majority  of  these  cases  will  be 
found  in  children  with  calculus  which  has  not  set  up  much 
cystitis.  In  adults  with  bleeding  tumour  which  is  not  associated 
with  inflammation,  another  class  favourable  to  vesical  closure 
will  be  found.  In  old  men,  the  most  favourable  conditions  to 
suture  can  scarcely  be  found  with  stone,  and  rarely  with  tumour. 
The  practice  of  complete  closure  of  the  wound  in  the  bladder 
will,  therefore,  be  mainly  confined  to  children.  A  mode  of  partial 
closure,  suitable  for  doubtful  cases,  and  advisable  with  the  view 
of  closing  up  opened  areolar  spaces,  will  be  described.  A  good 
many  are  best  treated  without  any  suture  at  all,  while  the  bladder 
is,  as  far  as  possible,  maintained  in  the  condition  of  an  open  and 
exposed  wound.  One  purpose  of  suture  of  the  bladder  is  to 
prevent  infiltration  of  urine :  if  the  suturing  is  not  perfect,  it 
adds  to  the  danger  of  infiltration  ;  and  the  risk  therefrom  being 
greatest  in  old  men  with  unhealthy  bladders,  in  these  the  treat- 
ment by  open  wound  is  most  frequently  called  for. 

Of  modes  of  suturing  the  bladder,  a  good  many  have  been 
described.  In  most  the  practice  adopted  has  been  founded  on 
the  principles  which  guide  the  suturing  of  wounds  of  the  intes- 
tine. It  may  be  pointed  out  that  the  outer  coverings  of  the 
bladder  in  this  operation  are  not  peritoneal,  and  do  not  exhibit 
the  same  tendency  to  rapid  healing  ;  that  the  whole  bladder 
wall  is  thicker  than  the  intestine,  although  perhaps  it  is  not 
more  tough  ;  and  that  the  mucous  membrane  of  the  bladder, 
unlike  that  of  the  intestine,  is  too  thin  to  act  as  a  plug  against 


SUTURING   THE  BLADDER.  689 

the  escape  of  fluid.  Further,  the  actual  line  of  incision  in  the 
bladder,  if  cleanly  cut  and  straight,  provides  two  broad  surfaces 
of  tissue  prone  to  unite  if  properly  approximated. 

One  of  the  most  ingenious  modes  of  suturing  the  bladder  is 
that  described  by  Maynard.*  The  sutures  are  placed  in  two 
double  rows  by  a  special  needle  before  the  bladder  is  opened, 
and  are  used,  during  the  opening  and  in  the  subsequent  manipu- 
lations, to  pull  the  bladder-walls  forward.  An  obvious  objection 
to  this  plan  is,  that  by  the  traction  the  stitch-openings  are 
stretched  and  dilated.  The  important  advantages  of  his  plan 
are,  that  it  gives  apposition,  not  only  at  and  beyond  the  margins 
of  the  wound,  as  in  Lembert's  mode,  but  also  at  the  cut  edges. 
The  most  generally  adopted  plan  is  Lembert's. 

I  should,  with  Maynard  and  a  good  few  others,  here  prefer 
chromicised  gut  to  silk  as  suture-material.  Suture  holes  in  the 
bladder  are  more  likely  to  leak  than  in  the  intestine,  for  the 
reasons  that  the  plug  of  mucous  membrane  below  them  is  not 
so  efficient,  and  that  sealing  up  of  the  openings  by  exuded 
lymph  is  not  so  rapid.  The  gut  swells  and  blocks  the  opening  ; 
and  if  it  should  come  in  contact  with  the  urine,  does  not  carry  it 
through  the  tissues  by  capillary  action  as  silk  does.  Chromicised 
gut  will  last  for  a  week  or  ten  days  at  least,  and  by  this  time  the 
full  benefit  of  suturing  will  be  secured.  Ordinary  carbolised 
gut  is  too  rapidly  absorbed. 

I  would  recommend  the  application  of  a  double  row  of 
sutures :  the  inner  row  to  transfix  the  cut  muscular  surface,  but 
not  the  mucous  membrane ;  the  outer  row,  after  the  manner  of 
Lembert.  Two  blunt  tenacula  or  aneurism  needles  are  placed, 
one  at  each  end  of  the  wound  in  the  bladder,  and  handed  over 
to  the  assistant  while  the  catch-forceps  are  removed.  The 
wound  is  gently  kept  on  the  stretch  by  this  means,  and  the  walls 
at  the  same  time  kept  forward.  A  round  semicircular  needle, 
with  piercing  but  not  cutting  point,  held  in  a  needle-holder,  is 
the  best  instrument  for  inserting  the  stitches.  Each  suture 
passes  through  the  edge  of  the  wound  obliquely  from  the 
outside,  close  to  but  not  piercing  the  mucous  membrane,  and 
*  Glasgow  Med.  Journ.,  Dec,  1887. 
45 


690  SUPRA-PUBIC  CYSTOTOMY. 

picks  up  as  much  of  the  muscle  as  possible  without  encroaching 
too  much  on  the  limit  to  be  covered  by  the  second  row  of 
sutures.  These  stitches  are,  in  fact,  placed  in  a  manner  not 
unlike  the  "  flange-stitch  "  of  Tait.  This  stitch  would,  in  fact, 
be  the  best  of  all  were  it  possible  to  separate  the  wall  of  the 
bladder  into  layers,  and  were  the  friable  muscle  competent  to 
bear  sufficient  strain ;  the  approximation  to  flanging  described 
would  probably  be  the  best  practical  method.  About  four 
stitches  to  the  inch  are  inserted  in  this  way.  While  the 
tenacula  continue  to  hold  the  wound  forwards  the  second  row 
is  now  placed,  after  Lembert's  method,  the  terminal  stitches 
passing  a  little  way  beyond  the  ends  of  the  wound.  They 
should  alternate  with  the  stitches  of  the  inner  row.  When 
inserted  the  ends  of  the  sutures  are  gathered  together  in  the 
hands  of  the  assistant,  the  tenacula  are  removed,  and  the  sutures 
are  then  tied  systematically  from  one  end  of  the  wound  to  the 
other.  When  all  have  been  tied,  their  ends  are  cut  off,  and  the 
bladder  permitted  to  fall  backwards  to  its  normal  position  when 
empty.  The  whole  supra-pubic  space  is  now  thoroughly 
cleansed  of  blood  and  fluid,  and  the  tap  removed  from  the 
irrigating  reservoir,  so  as  to  distend  the  bladder  and  test  the 
efficiency  of  the  suturing. 

There  is  no  objection  to  the  employment  of  the  continuous 
Dupuytren  suture,  if  the  surgeon  thinks  it  can  be  properly 
applied.  I  have  on  two  occasions  employed,  it  to  supplement  an 
interrupted  suture,  and  found  primary  healing  to  follow. 

The  parietal  wound  is  now  sutured,  after  a  drainage-tube  has 
been  placed  over  the  line  of  suture  in  the  bladder.  If  the  ends 
of  the  recti  have  been  divided,  a  good  deal  of  tension  may  be 
required  to  bring  the  lips  close ;  it  is  better  to  have  a  little  space 
gaping,  than  exert  too  much  traction.  The  tube  not  only  drains 
the  exudations  from  the  supra-pubic  space,  but  acts  as  a  safe- 
guard in  the  event  of  the  suturing  of  the  bladder  not  proving 
perfectly  efficient,  and  some  of  the  urine  escaping. 

Partial  suture  of  the  bladder  is  not  recommended  unless  the 
bladder  is  at  the  same  time  sutured  to  the  parietes,  as  in  the 
ordinary  treatment  of  an  abdominal  cyst  which  is  not  removed. 


AFTER-TREATMENT.  691 

In  old  men  the  bladder  lies  low  and  far  back,  and  it  prevents 
unnecessary  infiltration  of  urine  to  have  the  fundus  kept  well 
up  in  the  wound  by  means  of  a  stitch  or  two.  I  have  on  two 
occasions  treated  the  bladder  in  the  same  way  as  the  peri- 
toneum in  laparotomy — including  its  walls  bodily  in  the  stitches 
which  pass  through  the  parietes.  On  several  occasions  I  have 
spoken  of  the  possible  advantage  of  treating  the  whole  bladder- 
wound  in  this  way;  but  the  lower  part  of  it  I  have  always  found 
to  lie  too  low  down  to  be  easily  brought  up  to  the  parietes. 
Engelbach  and  Rollin*  have  written  in  favour  of  this  combined 
mode  of  suturing  bladder  and  parietes,  while  a  drainage-tube 
resting  in  the  bladder  passes  through  the  middle  of  the  wound. 
The  risk  of  this  method  is  that  drops  of  urine  passing  along  the 
stitches  may  get  into  the  peri-vesical  space.  One  or  two  stitches 
at  the  top  of  the  wound  placed  in  this  way  could  do  no  harm, 
and  might,  by  keeping  the  bladder  forward  and  diminishing  the 
wound- area,  do  much  good. 

After-treatment. — If  the  wounds  are  sutured,  an  ordinary 
dressing  is  applied,  and  fixed  b}^  strapping.  Many  surgeons 
recommend  that  the  bladder  be  kept  empty  by  wearing  a  cath- 
eter in  the  urethra.  Theoretically,  this  is  sound;  but  practically, 
in  children  at  least,  I  am  convinced  it  is  best  to  leave  the 
bladder  to  its  fate,  and  let  the  patient  pass  water  when  he  de- 
sires to.  I  have  on  two  occasions  seen  blocking  of  the  catheter 
cause  that  very  over-distention  which  we  wish  to  avoid,  and  on 
the  first  occasion  on  which  I  dispensed  with  the  catheter  I  got 
perfect  primary  healing.  Barker  and  others  have  come  to  the 
same  conclusion  ;  and,  therefore,  in  every  case  where  the  patient 
is  young,  and  the  bladder- wound  has  been  satisfactorily  sutured, 
I  should  dispense  with  the  catheter  fixed  in  the  bladder. 

If  the  wound  is  not  sutured  it  is  freely  dusted  with  iodoform 
or  boracic  acid  powder,  or  smeared  with  boro-glyceride,  and 
covered  with  large  pads  of  absorbent  dressing.  The  value  of  a 
drainage-tube  in  the  bladder  is  doubtful ;  I  have  thought  that  it 
causes  irritation  sometimes,  and,  if  the  lips  of  the  wound  remain 
*  Ann.  des  mat.  des  org.  gen.  urin.,  Sept.,  1887,  and  Med.  Chron.,  Dec,  18S7. 

45  * 


692  SUPRA-PUBIC  CYSTOTOMY. 

open,  I  dispense  with  it.  A  piece  of  rubber  tubing  acting  as  a 
syphon  in  connection  with  a  vessel  by  the  bedside  below  the 
level  of  the  patient  has  been  suggested  as  a  means  of  keeping 
the  bladder  empty.  As  soon,  however,  as  the  fluid  in  the 
bladder  was  exhausted  the  syphon  action  w^ould  cease.  If  it  is 
desirable  to  keep  the  bladder  empty,  this  can  be  done  by  capillary 
action,  using  a  small  roll  of  gauze  or  cotton  inside  a  drainage- 
tube  as  in  cases  of  abdominal  section.  The  dressing  is  fixed 
with  two  long  pieces  of  strapping,  and  the  patient  is  permitted 
to  lie  in  any  position  he  pleases.  Intra-abdominal  pressure  is 
quite  sufficient  to  keep  the  bladder  empty,  and  force  the  secreted 
urine  out  at  the  wound  ;  the  urine  has  no  more  tendency  to 
collect  in  the  bladder  in  the  supine  than  in  the  lateral  posture. 
Change  of  position  is  adopted  simply  because  it  adds  to  the 
patient's  comfort. 

If  primary  healing  after  suture  takes  place,  the  sutures  may 
be  removed  at  the  end  of  a  week,  and  the  patient  permitted  to 
get  up  in  ten  days.  If  localised  redness  and  swelling  appear  in 
the  supra-pubic  incision,  the  stitch  or  stitches  in  this  area  should 
at  once  be  removed.  In  some  cases  a  few  drops  of  urine  trickle 
out  through  the  wound,  to  be  followed  b}^  the  formation  of  a 
small  fistula,  which  spontaneously  closes  in  a  few  days.  If  the 
fistula  is  large,  so  as  to  permit  passage  of  all  or  the  greater 
part  of  the  secreted  urine,  healing  will  probably  not  take  place 
for  three  weeks  or  a  month.  In  children,  even  if  the  bladder- 
suture  has  completely  failed,  perfect  healing  is  rarely  delayed 
longer  than  three  weeks.  In  any  case  the  child  may  be  per- 
mitted to  get  up  and  run  about  at  the  end  of  a  fortnight.  In 
one  of  my  patients  in  whom  primary  healing  was  almost,  but  not 
quite  perfect,  a  free  discharge  of  blood  took  place  into  the 
bladder  at  the  end  of  ten  days.  Similar  experiences  have  been 
recorded  by  others.  Obvious  explanations  of  this  peculiarity 
suggest  themselves,  but,  in  the  absence  of  anything  like  clinical 
proof,  had  better  be  withheld. 

If  the  wound  is  not  closed  there  is  sometimes  a  tendency  for 
mucus  and  inflammatory  products  to  collect  in  the  bottom  of 
the  vesical   sac.      These    should   be  washed    out    as    often    as 


RESECTION  OF  THE  BLADDER.  693 

necessary  by  means  of  the  irrigator.  The  wound  and  every- 
thing in  its  neighbourhood  should  be  kept  sweet  by  frequent 
cleansing  and  the  emploj^ment  of  suitable  germicides.  At  the 
end  of  a  few  days,  if  the  patient  will  bear  it,  he  may  be  lifted  on 
a  sheet  into  a  warm  hip-bath,  placed  by  the  side  of  his  bed,  and 
left  there  for  half  an  hour  or  more.  If  this  can  be  done  daily,  it 
not  only  adds  to  the  patient's  comfort,  but  serves  thoroughly  to 
cleanse  the  parts. 

PARTIAL    RESECTION    OF    THE    WALL    OF    THE    BLADDER. 

This  operation  has  been  performed  only  three  or  four  times, 
and  has  scarcely  yet  attained  to  the  position  of  a  recognised 
proceeding. 

Sonnenberg*  was  the  first  to  perform  the  operation,  and 
related  his  case  at  the  Fourteenth  Congress  of  the  German 
Society  of  Surgeons  in  1885.  Von  Antal  of  Budapest  f  per- 
formed a  partial  resection  in  April,  1885;  and  Radzimowski,  a 
Russian  surgeon,  has  published  in  the  Kief  Vrach  for  1886 
a  similar  operation.  At  least  one  other  operation,  not  )'et 
published,  has  been  performed. 

Sonnenberg's  operation  was  performed  on  a  man  aged  sixty, 
who  had  a  malignant  tumour  in  the  anterior  wall  of  the  bladder. 
The  supra-pubic  operation  was  performed  in  the  usual  way;  and 
the  tumour  was  found  to  have  so  broad  a  base  that,  to  remove 
it,  it  was  necessary  to  resect  nearly  two-thirds  of  the  wall  of  the 
bladder.  The  tumour  was  removed  in  portions,  and  the  peri- 
toneal cavity  was  opened.  The  bladder  wound  could  not  be 
closed  ;  but  the  peritoneum  was  carefully  brought  together  by 
sutures  over  it.  The  bladder  was  drained  both  by  the  urethra 
and  by  the  parietal  wound.  The  patient  lived  four  weeks,  and 
died  of  asthenia.  At  the  post-mortem  it  was  found  that  a  new 
and  water-tight  cavity  had  formed,  which  seemed  capable  of 
being  distended. 

Von  Antal's  case  was  a  sub-peritoneal  resection.    His  patient 

*  "  Zur  partiellen  Resection  der  Harnblase,"  Verhandl.  d.  Deiitsch.  Gesel.  f. 
Chir.,  1885,  xiv.  12. 

t  Ccniralbl,  /.  Chir.,  1SS5,  p.  617. 


694  RESECTION   OF  BLADDER. 

was  a  man  aged  sixty-one,  and  to  remove  the  growth  about 
one-third  of  the  wall  of  the  bladder  had  to  be  removed.  The 
operation  was  retro-peritoneal,  the  whole  area  of  the  viscus 
invaded  by  the  tumour  having  been  peeled  from  the  peritoneum. 
Several  bleeding  vessels  had  to  be  tied  during  the  operation. 
The  edges  of  the  wound  in  the  bladder  were  closed  by  silk 
sutures,  drainage  tubes  were  inserted,  and  the  wounds  treated 
b}^  constant  irrigation  with  thymol  solution.  The  patient  made 
a  good  recovery,  with  a  fairly  capacious  bladder. 
Of  Radzimowski's  case  I  cannot  speak. 

In  carefully  selected  cases  there  can  be  no  doubt  that  partial 
resection  of  the  wall  of  the  bladder  is  both  feasible  and  proper. 
The  most  satisfactory  operation  would   be  where  the  tumour 
lay  entirely  in  the  anterior  wall,  when  it  could  easily  be  removed 
without    encroaching   upon  the    peritoneum.     A  tumour  lying 
behind  the  summit  of  the  bladder  may  be  resected  if  it  does 
not  involve  too  large  an  area  of  the  walls :  a  base  two  inches  in 
diameter  must  be  the  very  highest  limits  even  with  an  easily 
distended  bladder.   Removal  in  portions,  as  done  by  Sonnenberg, 
does  not  commend  itself  tome;  and  sub-peritoneal  resection  can 
rarely  be  advisable  if  the  tumour  deeply  infiltrates  the  bladder 
tissues,  for  then  the  peritoneum  is  likely  to  be  invaded  with  the 
new  growth.  Complete  excision  of  growth,  bladder- wall,  and  peri- 
toneum by  a  cutting  operation  would  probably  be  the  best  plan 
where  that  is  possible.     I  should  make  an  attempt  to  bring  the 
growth  well  into  the  bladder  wound  by  means  of  catch- forceps  ; 
then  by  longer  forceps  with  angled  blades  pinch  up  the  healthy 
bladder-walls  behind  it,  and  endeavour  to  make  a  closure  of  the 
health}^  walls  all  round  by  means  of  a  shoemaker's  stitch,  so  as 
to  close  the  bladder  behind  the  tumour  before  cutting  it  away. 
The    supra -pubic    incision   should   always   be    prolonged    into 
abdominal  section,  and  the  bladder  wound  is  then  more  thor- 
oughly closed  by  Lembert  sutures  placed  on  the  outside.    While 
this  is  being  done,  a  sponge  should  be  placed  inside  the  viscus 
to  make  it  bulge  into  the  abdominal  cavity,  and  so  to  soak  up 
the  secreted  urine ;  and  the  bowels  should  be  well  protected  by 
soft  flat  sponges  placed  inside  the  abdomen. 


Section  XIV. 


OPERATIONS    FOR  ABDOMINAL   INJURIES  AND 
INFLAMMATIONS. 


This  section  might,  not  improperly,  have  been  named  the 
Reparative  Surgery  of  the  Abdomen.  It  includes  the  whole 
subject  of  Abdominal  Traumatism,  so  far  as  it  can  be  dealt  with 
by  surgical  methods,  and  those  varieties  of  peritoneal  inflam- 
mations which  up  to  this  time  have  been  so  dealt  with. 
Abdominal  Injuries  are  specially  considered  under  the  heads  of 
Gunshot  and  Penetrating  Wounds,  and  Sub-parietal  Rupture 
of  the  Viscera,  hollow  and  soHd.  Abdominal  Inflammations 
are  treated  as  being  almost  identical  with  Suppurative  Peri- 
tonitis, and  specially  as  originating  in  ulcerative  perforation  of 
the  hollow  viscera,  in  septic  conditions  and  in  tubercular 
disease.  Clinically,  it  is  impossible  to  deal  with  these  on 
identical  lines,  or  with  even  balance  of  detail.     Thus,   special 


696"  GUNSHOT   WOUNDS. 

consideration  must  be  given  to  Gunshot  Wounds,  to  rupture  of 
the  Urinary  Bladder,  to  Rupture  of  the  Intestines,  and  to 
Perforative  Appendicitis.  These  may  be  regarded  as  types  of 
classes  from  the  clinical  standpoint ;  while  the  position  they 
hold  in  the  field  of  practice  makes  independent  treatment 
desirable. 


OPERATIONS    FOR  ABDOMINAL    INJURIES. 

Gunshot  Wounds  of  the  Abdomen. 

The  treatment  of  gunshot  wounds  of  the  abdomen  by 
laparotomy  is  one  of  the  latest  developments  of  modern  surgery. 
Up  to  1885,  according  to  Parkes,  only  six  operations  for  this 
class  of  operation  were  recorded.  Dr.  Kinloch  of  North  Carolina, 
operated  in  1863.  Coley*  tells  us  that  the  first  laparotomy  for 
gunshot  wound  of  the  abdomen  was  by  Baudens  in  1836.  He 
resected  eight  inches  of  the  small  bowel,  and  united  the  ends  by 
Lembert's  sutures.  After  the  death  of  the  patient  three  days 
later,  an  undiscovered  wound  of  the  caecum  was  found.  Baudens 
operated  a  second  time  for  wound  of  the  transverse  colon ;  in 
this  case  simple  closure  of  the  wound  was  followed  by  recovery. 
Kocher  of  Berne  had  a  success  in  1883.  Among  the  most  re- 
markable of  laparotomies  for  gunshot  wound  was  one  by  W.  T. 
Bull  of  New  York,  performed  in  1885,  in  which  no  fewer  than 
seven  intestinal  perforations  were  discovered  and  closed.  The 
patient  made  a  complete  recovery.!  To  this,  in  the  following 
year,  he  added  another  success  quite  as  remarkable. |  In 
Kocher's  case,|l  operated  on  three  hours  after  receipt  of  injury, 
the  stomach  was  perforated.  The  subject  was  forced  into 
prominence  by  the  interest  manifested  and  the  correspondence 
published  in  connection  with  the  murder  of  President  Garfield 

*  Bostoii  Med.  and  Surg.  Journ.,  Oct.  loth,  1888, 

t  Boston  Med.  and  Surg.  Journ.,  Nov.  27th,  1885, 

\  Ann.  of  Surg.,  Dec,  1885. 

I,  Corresp.  Bl.  f.  Schweiz.  Aertze,  Nov.  23rd  and  24th,  1883. 


ANATOMICAL   CONDITIONS.  697 

by  a  gunshot  wound  of  the  abdomen  ;  the  usually  hopeless 
results  of  these  injuries  when  untreated,  and  the  success  of  cer- 
tain operations,  combined  with  the  general  improvements  in 
abdominal  surgery,  have  now  resulted  in  placing  the  treatment 
of  gunshot  wounds  of  the  abdomen  among  justifiable  and  bene- 
ficial operations.  Towards  this  result  American  surgeons  have 
contributed  by  far  the  most  importarlt  part. 


ANATOMICAL   CONDITIONS. 

Although  in  recent  wars  there  has  been  no  lack  of  oppor- 
tunity for  studying  bullet  wounds  of  the  abdomen,  nor  dearth  of 
description  of  the  effects  produced,  yet,  from  the  fact  that  these 
reports  have  been  compiled  from  the  pathological  rather  than 
the  operative  standpoint,  we  have  few  definite  data  to  guide  us 
in  making  inferences  from  the  nature  of  the  external  wound  as 
to  the  character  of  the  lesion  produced.  Studies  of  the  results 
of  certain  experiments  on  the  lower  animals,  and  of  the  details 
furnished  in  the  descriptions  of  operations,  provide  valuable 
supplementary  knowledge  which  may  be  used  to  guide  us  in 
undertaking  these  operations. 

It  may  be  inferred  that  a  ball,  entering  the  walls  of  the 
abdomen,  pursues  a  straight  course  through  it.  It  is  true  that  a 
ball,  entering  the  parietes  at  one  point,  may  pass  in  a  curved 
direction  under  the  skin  and  make  exit,  or  be  embedded  at  a 
position  not  in  the  line  of  trajectory.  But  this  is  rare,  and  can 
occur  only  when  the  skin  is  struck  very  obliquely,  and  the  force 
of  the  ball  is  somewhat  spent.  If  the  ball  has  made  an  exit, 
the  practical  inference  must  be  that  its  course  has  been  in  a 
straight  line  between  the  points  of  entrance  and  exit,  unless 
there  are  positive  evidences — in  sub-cutaneous  discoloration,  or 
the  course  as  indicated  by  a  probe — that  the  reverse  is  the  case. 
If  the  ball  penetrates  the  parietes,  but  makes  no  exit,  we  must 
infer  injury,  greater  or  less,  to  the  underlying  organs. 

Some  information  may  be  derived  from  the  character  of  the 
parietal  wound.  A  large  wound  argues  a  large  ball  from  a  large 
firearm,    and,   in   the   majority   of    cases,    the   most    extensive 


698  GUNSHOT   WOUNDS. 

injuries.  It  is  true  that  shots  from  guns  are  usually  fired  at  a 
considerable  distance;  but  their  initial  force  is  usually  much 
greater  than  those  from  revolvers  which  are  fired  close.  From 
any  sort  of  firearm  a  close  shot  will,  in  most  cases,  cause  deep 
penetration ;  close  discharge  may  often  be  inferred  from  the 
presence  of  powder  marks  around  the  wound.  A  wound  that  is 
clean  cut,  and  equally  stained  all  round,  usually  indicates  that 
the  ball  has  struck  the  parietes  at  right  angles  to  the  surface. 
Unequal  staining  of  the  edges,  with  want  of  uniformity  in  the 
lips  of  the  wound,  suggest  oblique  impaction.  A  long,  abraded, 
or  bruised  track  of  surface,  leading  up  to  the  perforation,  sug- 
gests very  oblique  impaction,  with  a  possibility  that  the  cavity 
has  not  been  penetrated. 

It  is  rarely  possible  to  get  trustworthy  information  as  to  the 
course  of  the  bullet  from  the  position  which  the  wounded  person 
held  when  the  shot  was  fired.  We  may  be  told  that  the  shot 
was  fired  from  the  front,  or  the  side,  or  the  back ;  but  anything 
like  an  estimate  of  the  angle  at  which  the  body  was  struck  is 
rarely  provided  by  patient  or  onlookers.  Where  there  have 
been  struggles,  this  difficulty  is  increased ;  and  in  such  cases 
also  the  injury  may  have  been  inflicted  while  the  patient's  body 
was  bent  or  contorted,  so  that  the  track  of  the  ball,  with  the 
patient  in  bed,  may  be  devious,  while  it  may  have  been  per- 
fectly straight  in  the  position  held  during  the  infliction  of  the 
injury. 

It  will  be  seen,  therefore,  that,  in  the  case  of  one  wound,  a 
consideration  of  external  circumstances  will  at  best  supply  only 
probable  deductions  as  to  the  two  important  facts  of  penetration 
of  the  parietes  and  direction  of  the  ball.  In  a  few  cases  both 
probabilities  may  rank  almost  as  certainties ;  in  a  greater 
number,  one  inference  may  be  made  with  certainty,  while  the 
other  cannot ;  certainty  in  every  case  can  be  secured  only  by  an 
examination  of  the  wound  by  probing,  or  even  by  incision. 

The  nature  of  the  injuries  inflicted,  varying  according  to  the 
size  of  the  bullet  and  the  force  of  it,  and  according  to  the  angle 
of  impact  on  the  organ,  is  yet  fairly  constant  for  each  individual 
organ.     The  chances  of  any  individual  organ  being  struck  var}^ 


ANATOMICAL   CONSIDERATIONS.  69» 

directly  according  to  the  surface  it  presents.  A  ball  traversing 
the  anterior  parietes  can  scarcely  fail  to  injure  bowel,  while  the 
chances  of  injury  to  liver,  spleen,  kidney,  stomach,  or  bladder 
vary  according  to  the  route  of  the  ball  and  the  size  of  the  organ. 
Again,  a  ball  passing  perpendicularly  through  the  renal  cortex 
produces  very  different  results  from  one  passing  obliquely  along 
the  renal  vessels  and  through  the  pelvis.  A  ball  passing  clean 
through  the  right  lobe  of  the  liver  produces  very  different  effects 
from  one  crossing  the  track  of  its  great  vessels.  It  is  unneces- 
sary to  multiply  examples  of  effects,  which  must  suggest  them- 
selves to  every  surgeon.  For  practical  purposes,  the  size  and 
rapidity  of  the  projectile  may  be  ignored.  Although  a  large 
and  nearly  spent  ball  produces  more  extensive  injuries  than  a 
small  or  rapidly  moving  ball,  yet  the  effects  of  the  latter  are 
quite  serious  enough  to  greatly  endanger  life,  and  make  an 
almost  equally  urgent  claim  for  operative  treatment.  In  the 
case  of  a  rapidly  moving  and  small  ball  passing  obliquely 
through  the  thicker  walled  hollow  viscera,  such  as  the  stomach 
and  the  duodenum,  it  has  occasionally  been  noted,  once  during 
operation,  that  oblique  perforation  need  not  be  followed  by 
extravasation.  But  this  possibility  cannot  be  counted  upon  as 
a  probability :  if  the  contents  do  not  escape  at  once,  they  may 
do  so  later  on,  when  suppuration  or  sloughing  has  set  in.  For 
practical  purposes,  therefore,  perforation  of  the  hollow  viscera 
by  bullet-wound  must  always  be  reckoned  as  leading  to  extrava- 
sation of  visceral  contents. 

It  has  truly  been  said  that  the  tendency  of  every  gunshot 
wound  of  the  abdomen  is  towards  death.  In  the  great  majority 
of  cases  death  is  due  to  a  form  of  peritonitis  which  is  usually 
described  as  septic.  No  doubt  the  peritonitic  fluids  are  septic  ; 
but  it  is  doubtful  if  the  death  is  owing  to  true  blood-poisoning, 
rather  than  to  severe  shock.  In  more  than  go  per  cent,  of  the 
cases  attacked  with  peritonitis,  death  takes  place  within  fort}'- 
eight  hours.  It  is  true  that  the  peritoneum  has  a  limited  power 
of  disposing  of  septic  fluids.  The  experiments  of  Grawitz  and 
Wegner  showed  for  the  lower  animals  this  fact,  which  has  occa- 
sionally been  observed  in  human  beings.    But  this  power  of  the 


700  GUNSHOT    WOUNDS. 

peritoneum  has  an  infinitesimal  influence  in  lessening  the 
death-rate  from  this  class  of  injuries.  Even  if  there  has  been 
a  moderately  perfect  plastic  closure  of  a  perforation,  the  edges 
of  a  bullet-wound  are  so  liable  to  undergo  sloughing,  that  a 
secondary  perforation  usually  takes  place.  A  separated  slough 
cast  loose  into  the  cavity  has  great  dangers  of  its  own;  a  slough 
of  the  mesentery  which  cannot  fall  into  the  bowel  is,  in  this 
sense,  more  dangerous  than  one  on  the  intestinal  wall. 

Bleeding  is,  in  itself,  rarely  fatal ;  but  the  extravasated  blood, 
when  infected  by  free  visceral  fluids,  provides  pabulum  for  the 
extension  of  septic  inflammation,  and  so  adds  to  the  danger. 
A  small  number  of  deaths  has  been  caused  from  loss  of  blood 
through  division  of  some  of  the  large  vessels.  This  is  more 
likely  to  result  from  wounds  involving  the  solid  viscera  and 
their  vessels  than  from  injuries  to  the  hollow  viscera. 


SYMPTOMS    AND    DIAGNOSIS    OF   VISCERAL    INJURY. 

As  recent  practical  experience  and  accurate  clinical  records 
thereof  have  done  much  to  discredit  the  value  of  the  usually 
accepted  symptoms  of  perforations  of  viscera,  and  as  incontro- 
vertible physical  signs  are  very  rarely  met  with,  the  diagnosis 
must  in  many  cases  be  matter  of  inference  from  the  ascertained 
course  of  the  ball. 

Definite  physical  signs  are  afforded  when  there  is  escape 
through  the  parietal  wound  of  the  fluid  contents  of  any  of  the 
hollow  viscera,  such  as  bile,  faeces,  urine,  or  partially  digested 
food,  and  when  there  is  a  discharge  of  large  quantities  of  blood 
in  vomit,  faeces,  or  urine.  Both  sets  of  signs  are  very  rare  : 
and  the  value  of  the  escape  of  blood,  as  a  sign  of  injury  to  the 
hollow  viscera,  is  diminished  by  the  fact  that  a  severe  contusion 
may  cause  a  considerable  intra -visceral  haemorrhage.  The 
escape  of  a  large  quantity  of  gas  from  ruptured  bowel,  which 
rises  to  the  top  of  the  cavity,  and  causes  increase  of  resonance, 
and  perhaps  does  away  with  liver  dulness  by  getting  between 
liver  and  parietes,  has  been  spoken  of  as  an  unequivocal  sign. 


SYMPTOMS.  701 

Tympanites,  however,  may  produce  signs  very  closely  simulating 
the  presence  of  free  gas. 

Senn  of  Milwaukee,'"  after  a  series  of  carefully  conducted 
experiments,  has  recommended  the  method  of  inflation  by 
hydrogen  gas  for  the  purpose  of  diagnosing  visceral  perforation. 
He  himself  has  employed  it  in  three  cases  of  shot-wound,  and 
with  most  satisfactory  result  in  all.  In  one,  perforation  of  the 
stomach  could  scarcely  have  been  diagnosed  without  inflation ; 
and  in  the  two  others  rectal  inflation  was  of  value,  not  onl}^ 
in  proving  the  perforation,  but  in  showing  that  a  perforation 
low  down  in  the  sigmoid  flexure  had  been  overlooked  after  the 
operation  was  considered  concluded.  Mackie  of  Milwaukee,! 
Taylor  of  Philadelphia,!  and  a  few  others  who  have  employed 
the  method,  have  found  it  of  value.  The  gas  is  contained  in  a 
rubber  balloon,  and  in  the  tube  connecting  the  balloon  with 
rectum  or  stomach  is  a  manometer  to  register  the  pressure 
exerted  during  insufflation.  The  parietal  opening  being  made 
patulous,  the  gas  escapes  audibly,  and  may  be  ignited.  The 
flame  is  easily  extinguished  by  placing  a  wet  sponge  over  it. 
Hydrogen  gas  is  preferred  on  account  of  its  low  specific  gravity, 
thus  always  rising  to  the  surface ;  its  harmless  nature,  and  its 
being  readily  ignited. 

Dulness  on  percussion,  either  in  the  track  of  the  ball,  or 
in  the  dependent  portions  of  the  abdomen,  is,  if  present  in 
marked  degree,  evidence  of  extravasation  of  fluids  or  blood. 
Localised  dulness  would  usually  be  taken  as  indicating  haemor- 
rhage: diffuse  dulness,  extravasation  of  visceral  fluids.  But  either 
sign  must  be  of  rare  occurrence,  and  where  the}^  do  occur  might 
only  indicate  that  certain  portions  of  bowel  are  at  that  moment 
more  full  of  fluid  than  other  portions.  The  rapid  occurrence  of 
tympanites,  too,  which  is  most  marked  on  the  anterior  abdominal 
surface,  may  leave  the  dependent  portions  relatively  dull  to 
percussion.  Emphysema  of  the  abdominal  wall  in  the  neigh- 
bourhood of  the  wound  is  occasionally  observed,  but  it  is  rare, 
and  it  may  occur  without  penetration  of  viscera. 

*  Phila.  Med.  News,  August  25th  and  Nov.  loth,  1888,  and  Trans.  Amer. 
Med.  Assocn.,  1888.  t  Phila.  Med.  Neivs,  June  9th,  1888.        J  Ibid. 


702  GUNSHOT    WOUNDS. 

The  presence  of  blood  in  the  urine  indicates,  according  to 
the  position  of  the  wound,  injury  to  kidney,  ureter,  or  bladder. 
But  extensive  injury  to  any  of  these  organs  may  exist  without 
the  appearance  of  haematuria. 

Injury  to  nerves  or  spinal  cord  will  show  itself  in  paralysis 
of  the  supplied  parts.  Injury  to  vascular  trunks  is  inferred 
from  the  absence  of  pulsation  in  the  femoral  vessels. 

Shock  is  frequently  mentioned  as  an  invariable  sequence 
of  perforating  wounds  of  the  viscera.  Experience  has  shown 
that  it  is  an  exceedingly  variable  symptom,  being  frequently 
marked  in  unimportant  cutaneous  wounds,  while  it  may  be 
completely  absent  in  the  worst  cases  of  perforation.  In  some 
cases,  it  is  nothing  more  than  nerve-prostration  from  terror  ; 
in  others,  it  is  produced  by  free  haemorrhage,  or  rapid  extra- 
vasation of  visceral  fluids.  In  no  case  can  its  immediate 
occurrence  be  said  to  be  indicative  of  visceral  perforation. 
Further  help  may  be  derived  from  an  observation  of  the 
condition,  as  to  its  increasing  or  diminishing  in  degree,  and 
as  to  its  capacity  to  be  influenced  by  mental  stimulus.  It  is 
sometimes  observed  on  the  battle-field  that  a  man  found  in  a 
condition  of  profound  shock,  on  being  told  by  the  surgeon  that 
he  has  received  only  a  slight  contusion  on  the  abdomen,  has  his 
nervous  vigour  at  once  restored,  and  returns  to  the  fighting. 
Reassurance  may  help  to  remove  nerve-shock.  True  "  abdo- 
minal shock"  from  extravasation  of  fluid  into  the  cavity  cannot 
thus  be  charmed  away.  It  is  probable,  however,  that,  in  spite 
of  many  notable  exceptions,  perforation  of  any  of  the  abdominal 
viscera  would,  in  the  majority  of  instances,  be  followed  by  shock 
more  or  less  severe. 

One  of  the  most  important  symptoms  is  a  feeling  of  nausea, 
frequently  accompanied  with  vomiting.  This  is  not  common  in 
false  shock,  while  in  a  considerable  number  of  cases  of  un- 
doubted perforation  it  was  present  in  greater  or  less  degree. 
Our  estimate  of  the  value  of  this  symptom  is  certainly  not 
diminished  by  a  knowledge  of  its  import  in  other  abdominal 
lesions. 


MORTALITY.  703 

MORTALITY. 

Morton  of  Philadelphia,*  Sir  William  MacCormac,t  N.  B. 
Carson|  of  St.  Louis,  and  Barker  §  of  London,  have  compiled 
elaborate  tables  of  all  the  cases  of  operations  performed  for  ab- 
dominal injury.  Morton's  tables,  including  cases  of  shot-wound 
recorded  up  to  the  end  of  1886,  give  22  operations  with  5  recov- 
eries. MacCormac's  tables,  extending  up  to  May,  1882,  include 
32  cases,  with  seven  recoveries,  one  (Pirogoff's)  being  doubtful. 
Carson's  tables,  extending  to  June,  1887,  include  43  cases:  of 
these,  13  recovered  ;  one  (Pirogoff's)  was  progressing  favourably 
at  the  end  of  four  days,  and  was  then  lost  sight  of.  Barker's 
tables  add  26  cases  to  MacCormac's  32,  giving  58  cases  alto- 
gether with  35  deaths.  Of  these  26,  16  recovered  and  10  died, — 
a  marked  improvement  on  the  earlier  results.  W.  B.  Coley  |1 
has  collected  74  cases  with  29  recoveries.  The  most  recent  and 
most  complete  statistics  of  abdominal  section  for  traumatism, 
presented  at  the  Newport  meeting  of  the  American  Medical 
Association  by  Morton  in  i88g,  give  no  cases  of  section  for 
perforating  gunshot-wounds,  with  36  recoveries — a  mortality  of 
62  per  cent.  The  total  mortality,  considering  the  nature  of  the 
injuries,  the  usual  condition  of  the  patient  when  placed  on  the 
operating  table,  and  the  necessarily  tentative  nature  of  the 
earlier  operations,  cannot  be  regarded  as  other  than  exceed- 
ingly satisfactory. 


INDICATIONS    AND    CONTRA-INDICATIONS    TO    OPERATION. 

Of  all  penetrating  gunshot-wounds  of  the  abdomen,  nearly 
eighty-eight  per  cent,  are  fatal.  When  involving  the  stomach 
or  intestines,  "  these  wounds  may  always  be  expected  to 
cause   death,    generally   from    peritonitis   following   extravasa- 

*  Journ.  Amer.  Med.  Assn.,  Feb.  26th,  1887. 

t  Abd.  Sect-  for  the  Treatment  of  Intra-Peritoneal  Injury.     Lond.,  18S7. 

\  Jour.  Amer.  Med.  Assn.,  Nov.  5th,  1887. 

§  Brit.  Med.  Journ.,  March  17,  1888. 

II  Abst.  in  Journ.  Amer.  Med.  Assn.,  Nov.  10,  1888, 


704  GUNSHOT   WOUNDS. 

tion,  or  from  very  acute  septicsemia."  Otis "  tell  us  that 
only  six  or  seven  unequivocal  recoveries  from  shot-wounds 
of  the  stomach  are  known,  iistulse  being  left  in  two  of  them ; 
while  he  doubts  if  there  is  even  one  "incontestable  instance 
of  recovery  from  wound  of  the  small  intestine."  In  shot- 
wounds  of  the  large  intestine  the  prognosis  is  more  favourable  ; 
about  20  per  cent,  recovering,  with  or  without  stercoral  fistula. 
Wound  of  the  gall-bladder  is  almost  certain  to  cause  death 
from  extravasation.  Under  the  best  palliative  treatment,  death 
almost  inevitably  takes  place.  Therefore,  if  a  desperate  remedy 
is  ever  admissible  in  a  desperate  disease,  it  certainly  is  so  in 
gunshot  wounds  of  the  abdominal  viscera.  Operation  by  ab- 
dominal section  is  certainly  a  desperate  remedy,  but  it  has 
already  been  proved  to  be  far  better  than  none. 

The  known  tendencies  of  penetrating  ball-wounds  of  the 
viscera  being  admitted,  the  indication  to  operate  follows  of 
necessity  on  proof  of  the  receipt  of  injury.  By  operation  alone 
can  the  parts  be  put  into  such  a  condition  that  spontaneous 
recovery  is  probable,  or,  it  might  almost  be  said,  possible.  By 
operation  we  can  check  haemorrhage ;  we  can  prevent  extra- 
vasation if  it  has  not  already  taken  place,  and  remove  noxious 
fluids  if  it  has  taken  place ;  and  we  can  provide  free  drainage 
if  septic  peritonitis  has  set  in.  A  mere  recapitulation  of  the 
anatomical  conditions  provides  the  indications  for  operation. 

But  contra-indications  exist.  Firstly,  we  must  have  regard 
to  the  condition  of  the  patient.  Profound  collapse  which  is  not 
due  to  haemorrhage  is  a  contra-indication  of  weight  corresponding 
to  the  gravity  of  the  condition.  Such  collapse  existing  a  few 
hours  after  receipt  of  injury  is  not  so  favourable  as  when  it 
has  continued  for  a  day  or  more.  In  the  former  case  the  vital 
powers  are  not  so  much  exhausted,  and  are  more  susceptible  to 
resuscitating  influences ;  in  the  latter  case  diffuse  peritonitis 
ma}^  be  present,  which  demands  a  somewhat  tedious  manipula- 
tion during  operation,  and  makes  a  prolonged  call  on  the 
energies  of  the  patient  during  cure.  Undoubted  and  severe 
peritonitis  existing  on  the  second  or  third  day  is  by  most 
*   P.   S.  Conner,  Internat.  Cyc.  Surg.,  vol.  ii.,  p.  193. 


WHEN   TO   OPERATE.  705 

authorities  recognised  as  a  contra-indication.  In  such  cases,  it 
is  improbable  that  the  sites  of  perforation  would  be  found  ;  and 
if  they  were,  that  they  could  be  dealt  with  without  the  production 
of  excessive  traumatism.  There  is  little  use  in  cleansing  the 
cavity  if  it  is  to  be  at  once  refilled,  and  there  is  little  use  in 
looking  for  the  perforations  if  they  can  neither  be  closed  nor 
fixed  in  the  wound,  while  there  is  positive  danger  in  adding  to 
the  risk  from  traumatism.  In  such  cases  the  most  that  can  be 
done  is  to  make  a  small  parietal  opening  with  the  help  of  local 
anaesthesia,  and  permit  the  discharge  of  the  noxious  fluids  and 
secretions,  giving  the  patient  the  benefit  of  the  remote  chance 
of  spontaneous  cure  with  intestinal  fistula. 

An  important  practical  question  is  as  to  the  best  time  for 
operation.  In  a  general  way,  it  may  safely  be  said  that  operation 
should  be  performed  as  soon  as  possible  after  it  has  been  ascer- 
tained that  there  is  perforation  of  peritoneum.  Coley's  statistics 
show  that  of  39  cases  operated  upon  within  twelve  hours  i8  recov- 
ered, while  of  22  operated  upon  after  twelve  hours  only  five  recov- 
ered. The  chance  of  recovery  would  thus  seem  to  be  greatly  in- 
creased by  early  operation.  Symptoms  must  not  be  waited  for;  they 
are  often  misleading  when  present,  and  their  continued  absence 
is  compatible  with  the  receipt  of  injuries  which  must  inevitably 
lead  to  death.  If  there  is  much  shock,  the  operation  may  be 
put  off  while  the  patient  is  closely  watched  and  treated  for  an 
improvement  which  would  justify  operation.  The  possibility  of 
the  shock  being  due  to  haemorrhage  must  not  be  overlooked. 
In  this,  as  is  in  so  many  other  conditions,  nearly  everything  must 
be  left  to  the  educated  judgment  of  the  surgeon  ;  it  is  impossible 
to  provide  specific  or  absolute  rules  for  guidance. 


OPERATIVE     TREATMENT. 

If  the  patient  is  feeble  or  collapsed,  an  enema  containing 
brandy  should  be  given  before  the  anaesthetic  is  administered. 
The  parietes  must  be  thoroughly  cleansed,  and  the  pubic  hair,  if 
it  lies  near  to  the  seat  of  injury  or  operation,  must  be  shaved. 

46 


706  GUNSHOT    WOUNDS. 

The  perforated  rubber  sheet,  if  it  can  be  used  without  encroach- 
ing on  the  field  of  operation,  should  be  fixed  in  position. 

The  instruments  are  the  ordinary  ones  in  use  for  abdominal 
section,  with  the  addition  of  four  or  more  of  Makins's  intestinal 
clamps.  At  least  a  dozen  of  the.  round  milliner's  needles 
recommended  for  enterorraphy,  ready  threaded  with  silk  of  suit- 
able size,  are  provided.  Thick  prepared  catgut  should  be  in 
readiness,  in  case  it  is  necessary  to  close  wounds  in  the  solid 
viscera.  A  number  of  sponge-cloths  and  flat  and  round  sponges 
are  kept  ready,  in  warm  antiseptic  lotion.  A  large  fountain 
reservoir,  with  rubber  tubing  and  glass  nozzle  attached  for 
irrigation,  is  placed  in  a  convenient  situation  some  feet  above 
the  level  of  the  patient.  A  receptacle  placed  under  the  operating 
table,  for  collecting  the  fluid  which  escapes  from  the  abdomen 
during  irrigation  and  trickles  over  the  large  macintosh,  will  be 
found  convenient. 

The  Parietal  Incision. — Nearly  all  writers  on  the  subject  re- 
commend the  median  incision.  MacCormac,  Parkes,  Nancrede, 
Bull,  and  Morton  insist  upon  the  median  incision,  and  give 
numerous  cogent  reasons  for  their  views.  Morton  says  that  in 
nearly  all  the  successful  operations  the  median  incision  was  em- 
ploj-ed.  Since  he  wrote,  however,  at  least  five  successful 
operations  through  incisions  not  median  have  been  recorded. 
Professor  McGraw  of  Detroit  vigorously  protested  against  the 
uniform  wisdom  of  this  plan  ;  but  his  protests  seem  to  have  been 
ignored  by  subsequent  writers. 

There  can  be  no  doubt  that,  as  affording  most  space  for  a 
general  exploration  of  the  whole  cavity  and  its  contained  viscera, 
the  median  incision  is  best.  In  cases  where  the  course  of  the 
ball  has  been  across  the  middle  line,  entering  at  one  side  and 
passing  towards  the  other ;  and  in  others  where  the  ball,  enter- 
ing near  the  middle  line,  passes  either  directly  backwards,  or  in 
an  uncertain  direction,  vertically  or  laterall}^  then  the  median 
incision  is  indicated.  Also,  in  all  cases  where  the  course  of  the 
ball  is  unknown,  the  median  incision  is  the  best.  On  the  other 
hand,  there  are  cases  where  an  incision  not  median  is  indicated. 


PARIETAL  INCISION.  707 

A  ball  injures  only  such  organs  as  lie  in  its  course.  Reason  and 
experiment  combine  to  show  that  balls  passing  through  the  soft 
tissues  of  the  abdomen  pursue  a  course  that  is  almost  straight. 
If  there  is  deflection,  it  is  in  the  great  majority  of  cases  in  ac- 
cordance with  the  law  of  equality  of  the  angles  of  incidence  and 
reflection.  The  erratic  courses  of  balls  sometimes  met  with 
occur  in  cases  where  the  skin  is  perforated  at  a  very  oblique 
angle,  and  can  rarely  apply  to  gunshot  wounds  of  the  ab- 
domen. It  may  be  safely  inferred  that  a  ball  passing  through 
the  abdominal  cavity  follows  the  course  it  had  on  perforating  the 
parietes ;  if  deviations  take  place  after  it  has  struck  bones  or 
hollow  viscera,  these  do  not  influence  the  scheme  of  operation. 
Thus,  in  such  a  case  as  that  of  Barker,*  where  the  ball  entered 
three  inches  internal  to  the  anterior  iliac  spine,  the  lateral  in- 
cision which  he  adopted  was  better  than  a  median  incision  could 
have  been.  A  case  of  McGraw's,  in  which  the  colon  only  was 
wounded,  is  evidence  in  the  same  direction  ;  and  several  similar 
cases  might  be  quoted. 

It  is  not,  however,  a  question  of  mere  convenience  of  ex- 
amining viscera,  but  also  of  adding  to  traumatism.  The  whole 
length  of  the  intestine  and  all  the  fixed  viscera  cannot  be 
systematically  examined  with  impunity.  Only  those  fixed 
organs  which  lie  in  the  course  of  the  ball  need  be  examined  ; 
and  in  the  case  of  the  movable  intestines,  common  sense  must 
be  our  guide  in  deciding  as  to  the  extent  to  which  examination 
must  be  carried.  Thus,  if  a  ball  passes  through  the  right  lum- 
bar region,  perforating  the  ascending  colon  on  its  anterior  and 
posterior  aspects,  there  is  no  necessity  for  examining  the 
stomach,  or  transverse  and  descending  colons,  or  more  of  the 
small  bowel  than  lies  near  to  the  seat  of  injury.  It  is  unnecessary 
to  multiply  examples ;  they  will  at  once  suggest  themselves. 
It  is  true  that  the  intestines  may  move  some  distance  away 
from  the  track  of  the  ball,  and  this  distance  may  be  increased 
according  to  the  length  of  time  which  has  elapsed  since  the 
receipt  of  injury.  But  intestines  can  scarcely  move  from  epi- 
gastric or  umbilical  regions  to  the  bottom  of  the  pelvis ;  or 
•  Brit.  Med.  Jount.,  Nov.  26th,  1887. 
46  * 


708  GUNSHOT    WOUNDS. 

from  the  right  lumbar  region  to  the  left.  And  the  fixed  organs 
cannot  move  at  all.  We  need  not  overdo  the  certainty  of  proving 
integrity  of  viscera  at  the  expense  of  increasing  the  patient's 
risks. 

The  line  of  incision  must  be  guided  by  reasonable  deductions 
from  the  indications  as  to  the  course  of  the  bullet.  To  the 
operator  the  major  premise  in  this  course  of  reasoning  must  be 
the  course  of  the  ball  through  the  parietes.  I  entirely  fail  to 
appreciate  the  force  of  the  arguments  so  frequently  urged 
against  probing  of  the  wound.  Where  a  ball  has  passed,  surely 
a  probe  may  follow  without  much  increase  of  danger.  I  should 
always  probe  the  wound,  using  a  very  blunt  instrument,  which 
cannot  be  insinuated  into  the  inter-muscular  spaces ;  and  this 
probe  I  should  leave  in  the  track  of  the  ball  if  its  presence  were 
of  the  slightest  assistance  in  showing  the  line  of  injury.  To  lay 
open  the  track  is  in  most  cases  unnecessary. 

The  line  of  incision  should  be  guided  by  a  simple  process  of 
reasoning  as  to  the  inferred  and  probable  course  of  the  ball, 
deduced  from  the  site  of  the  aperture  of  entrance  and  the 
course  of  the  ball.  To  the  skilled  operator  (and  no  other  should 
undertake  these  cases)  it  is  a  matter  of  absolute  indifference 
where  entrance  into  the  abdominal  cavity  is  made.  The 
objections  of  increased  haemorrhage,  and  division  of  muscular 
planes,  usually  urged  against  incisions  made  not  in  the  linea 
alba  or  the  linea  semilunaris,  are  not  for  a  moment  to  be 
considered  against  increased  facility  of  access  to  abdominal 
organs. 

What  is  to  be  the  exact  line  of  incision  it  is  impossible  in 
general  terms  to  indicate.  In  every  case  the  inference  should  be 
that  the  organs  injured  lie  in  the  line  of  the  ball,  as  shown  by 
the  course  it  pursues  through  the  parietes,  and  the  incision 
should  be  made  accordingly.  It  is  probably  true  that  the  line 
of  incision  will  in  most  cases  fall  to  be  made  in  the  middle  line ; 
but  in  an  important  minority  the  incision  will  be  guided  accord- 
ing to  the  principles  indicated.  In  general  terms  it  may  be  said 
that  the  middle  of  the  line  of  parietal  incision  should  lie  over  an 
imaginary  point  situated  midway  between  the  point  of  the  probe 


THE  OPERATION.  709 

in  the  ball-track  resting  on  the  peritoneum  and  the  opposite 
wall  of  the  cavity. 

The  length  of  the  incision  must  be  regulated  by  the  thickness 
of  the  parietes,  the  firmness  and  tension  of  the  muscles,  the 
degree  of  distension  of  the  bowels,  and  the  amount  of  injury 
probable  or  ascertained.  It  need  be  neither  vertical  nor  trans- 
verse, but  be  regulated  in  length  and  made  in  direction  entirely 
as  the  reasoning  of  the  surgeon,  based  on  the  premises  indi- 
cated, directs.  Beyond  this  it  is  probably  unnecessary  to 
specify   directions. 

The  parietes  being  incised  to  the  length  desired,  the  lips  of 
the  wound  are  kept  apart  by  retractors  in  the  hands  of  the 
assistant.  The  self-retaining  retractors  recommended  for 
certain  cases  of  supra-pubic  cystotomy  (Fig.  82)  will  suit  the 
purpose  admirably,  and  do  not  require  holding. 

The  end  of  the  bullet-track  where  it  strikes  the  perito- 
neum is  first  examined,  to  see  that  no  haemorrhage  is  going 
on,  and  to  make  finally  certain  as  to  the  fact  of  perforation. 
The  ragged,  and  perhaps  foul,  opening  is  cleansed  with  an 
antiseptic,  and,  if  it  is  large,  is  at  once  closed  by  a  con- 
tinuous crossing  stitch.  Any  blood-clot  which  obscures  the 
field  of  operation  is  mopped  up  gently,  without  disturbing  the 
intestines.  A  systematic  examination  of  all  the  viscera  which 
lie  in  or  near  the  track  of  the  ball  is  now  carried  out.  If 
haemorrhage  is  going  on,  the  source  of  it  should  at  once  be 
sought  for  before  doing  anything  else.  It  must  be  remembered 
that  manipulation  may  set  up  vermicular  contraction  of  the 
intestines,  leading  to  displacement  of  their  wounds  from  the 
line  of  injury;  therefore,  any  wound  or  serious  contusion 
observed  during  the  exploration  for  bleedmg  points  should  at 
once  be  grasped  in  catch-forceps,  which  are  left  attached. 
Again,  when  the  bleeding  point  has  been  discovered,  it  may 
be  temporarily  secured  by  pressure-forceps  while  an  opening  in 
the  bowel  which  is  discharging  faeces  is  being  closed.  No  defi- 
nite order  of  procedure  can  be  laid  down.  The  most  urgent 
calls  are  attended  to  first :  the  less  grave  injuries,  while  they 
may  be  temporarily  diminished  by  judicious  placing  of  forceps 


710  GUNSHOT    WOUNDS. 

or  sponges,  are  left  to  the  end.  A  rapid  survey  of  all  the  parts 
is  made  when  the  dangerous  haemorrhage  or  abundant  extrava- 
sation has  been  checked,  and  the  full  extent  of  the  injuries 
inflicted  is  finally  ascertained.  We  now  proceed  to  the  surgical 
repair  of  these  injuries. 

At  this  stage,  if  there  has  been  extravasation  of  visceral 
contents,  I  should  recommend  that  abdominal  irrigation  should 
be  commenced  and  continued  while  the  closure  of  visceral 
wounds  is  being  carried  out.  The  irrigating  fluid,  if  conducted 
over  the  macintosh  into  the  receptacle  provided,  need  not  be  in 
the  way  ;  it  is  cleansing  the  abdomen,  and  so  saving  time  ;  and, 
perhaps  most  important  of  all,  if  the  fluid  is  used  at  a  tempera- 
ture of  105°,  it  will  be  found  an  excellent  means  of  treating 
shock.  The  stream  should  be  a  gentle  one,  such  as  an  elevation 
of  the  reservoir  of  a  foot  and  a  half  above  the  patient  would 
give.  An  excellent  method  of  conveying  the  irrigating  fluid 
into  the  abdomen  for  this  operation  would  be  to  employ  the 
long  rubber  double  tubes  now  in  use  for  washing  out  the 
stomach.  As  the  parietal  wound  does  not  closel}''  fit  the  tube, 
only  a  portion  of  the  fluid  would  escape  out  of  the  evacuating 
tube  ;  but  this  is  of  small  moment. 

The  assistant  will  meanwhile  be  looking  after  the  forceps 
attached  to  the  wounds  of  bowel  or  other  organs,  holding  them 
in  a  bunch  at  the  position  requiring  least  traction  in  the  wound. 
This  plan  of  operation  is  not  that  usually  recommended.  Sur- 
geons hitherto  have  almost  uniformly  advised  immediate  and 
complete  suture  of  an  injury  as  soon  as  it  is  discovered.  But 
this  suturing  is  a  tedious  and  irritating  process,  and  during  the 
carrying  out  of  it  the  intestines  will  be  acting  violently,  dis- 
placing other  injured  portions  and  adding  to  the  amount  of 
extravasation.  The  only  advantage  of  immediate  suturing  is 
that  no  perforation  is  afterwards  overlooked  :  forceps  attached 
to  the  edges  of  the  perforation,  or  the  middle  of  the  contusion, 
secure  this  advantage  just  as  well. 

Sponge-cloths  are  now  arranged  round  the  opening :  the 
surgeon  pulls  one  pair  of  forceps  to  the  surface,  and  examines 
the  wound  in  the  intestine.  The  other  forceps  are  now  gathered 


THE   OPERATION.  711 

together  and  laid  between  the  folds  of  a  cloth,  while  the  assistant 
prepares  to  help  the  operator.  The  injured  bowel  is  care- 
full}'  examined,  and  the  mode  of  treatment  decided  upon.  A 
slight  contusion  may  be  left  to  its  fate.  A  moderately  severe 
contusion  may  be  doubled  inwards,  and  Lembert's  suture  or  a 
continuous  Dupuytren  suture  placed  in  the  healthy  bowel  beyond 
it,  so  that  if  it  does  become  gangrenous  the  slough  will  be  dis- 
charged into  the  lumen  of  the  gut,  and  cannot  escape  into  the 
general  cavity.  In  cases  of  perforation  at  the  free  border  of 
the  bowel,  we  may  adopt  simple  closure  after  cleansing  of  the 
edges  of  the  wound,  or  closure  after  resection  of  the  bruised 
edges,  as  seems  at  the  time  most  convenient  and  safe.  Lem- 
bert's suture  (see  Enterorraphy)  will,  in  the  great  majority  of 
cases,  be  found  the  best.  For  a  small  perforation,  a  continuous 
suture  will  be  found  perfectly  efficient.  The  direction  of  the  line 
of  suture  would  seem  to  be  of  little  importance.  Multiple 
perforations  occupying  a  small  piece  of  bowel  may  require  a 
more  extensive  resection,  up  to  complete  removal  of  the 
whole  calibre.  This  is  carried  out  exactly  after  the  manner 
described  for  Enterectomy  and  Enterorraphy,  and  need  not 
again  be  described. 

During  these  manipulations  the  bowel  will  be  lying  on  a  soft 
sponge-cloth  placed  by  the  side  of  the  parietal  wound.  Usually 
no  clamp  will  be  required,  the  fingers  of  the  assistant  being 
quite  efficient.  If  resection  is  to  be  carried  out,  I  should  recom- 
mend the  employment  of  Makins's  clamps.  During  the  operative 
proceedmg,  a  sponge  or  two  placed  over  the  viscera  will  prevent 
their  being  extruded.  A  small  space  should  be  left  by  the  side 
of  the  irrigating  tube  to  permit  the  outflow  of  fluid. 

A  wound  at  the  mesenteric  border  is  a  more  serious  affair. 
A  wound  passing  through  the  mesentery  close  to  the  bowel,  or 
through  the  mesenteric  border  of  the  bowel,  will  usuall3^  by 
occlusion  of  the  intestinal  vessels,  lead  to  gangrene  of  portions 
of  intestine  involved.  For  this  injury  the  treatment  must  be 
resection  of  bowel,  along  with  the  perforated  wound  of  the 
mesentery.  If  it  be  not  necessary  to  remove  a  piece  of  mesen- 
tery that  is  actually  wedge-shaped,  the  lines  of  incision  should 


712  GUNSHOT    WOUNDS. 

at  least  go  well  beyond  the  seat  of  injury.  The  wounds  are 
united  exactly  as  described  for  Enterorraph}^ 

Each  wound  after  it  is  closed  is  thoroughly  cleansed,  and 
the  bowel  is  returned  to  the  cavity.  When  all  the  intestinal 
wounds  discovered  at  the  first  examination  have  been  closed, 
the  bowels  are  pushed  to  one  side,  and  kept  there  by  a  large 
sponge,  while  the  underlying  solid  viscera  are  examined.  If 
the  site  of  lodgment  of  the  ball  can  be  detected,  an  attempt 
should  be  made  to  remove  it.  Bleeding  vessels  are,  of  course, 
secured. 

Perforations  in  the  stomach  are  dealt  with  in  the  same  way 
as  in  the  intestine.  A  perforation  in  the  posterior  wall  can  be 
reached  only  after  making  an  opening  through  the  layers  of  the 
gastro-colic  omentum.  If  it  cannot  be  sutured  by  this  route,  it 
may  be  reached  from  the  front  after  gastrotomy,  as  recommended 
for  perforating  ulcer  of  the  stomach  on  its  posterior  aspect. 
In  these  cases  extravasation  of  gastric  contents  nearly  always 
takes  place,  and  irrigation  and  cleansing  will  have  to  be 
specially  thorough. 

Wounds  of  the  omentum  are  occasionally  attended  with  free 
bleeding,  which  may  form  a  large  hgematoma  between  its  layers. 
In  such  a  case  complete  amputation  of  the  omentum  above  the 
site  of  injury  would  be  the  best  treatment.  A  small  perforation 
without  bleeding  should  be  excised,  to  prevent  the  risks  of  gan- 
grene, and  the  opening  should  be  closed  by  a  continuous  suture. 

Wounds  of  the  liver  are  by  no  means  necessarily  fatal : 
Edler's  elaborate  tables"''  show  that  of  uncomplicated  cases 
of  shot-wound  only  39.1  per  cent,  died,  while  of  all  cases  ^^ 
per  cent.  died.  The  duration  of  cure  was  usually  prolonged 
from  the  presence  of  foreign  bodies  in  the  wound,  and  particu- 
larly splinters  of  bone  from  the  ribs :  this  fact  suggests  the 
propriety  in  such  cases  of  seeking  for  foreign  bodies,  and 
removing  them  if  found.  Suppurative  inflammation  was  the 
most  frequent  cause  of  death  (37.5  per  cent.) ;  haemorrhage  was 
the  cause  in  20  per  cent,  of  the  cases.  Therefore,  cleansing  of 
the  wound  should  be  as  perfect  as  possible,  and  should  be  carried 
*  Langenbeck's  Archiv.  f.  Klin  Cliir.,  Bd.  xxxiv. 


WOUNDS   OF   THE  KIDNEY.  715 

out,  not  only  by  means  of  irrigation  with  a  soft  catheter  of  small 
size  introduced  along  the  track  of  the  wound,  but  also  by  friction 
with  a  small  pledget  of  cotton  rolled  around  the  end  of  a  probe 
and  saturated  with  an  antiseptic.  Bleeding  must  be  checked 
either  by  the  insertion  of  deep  catgut  sutures,  or  by  plugging  the 
wound  with  a  strip  of  antiseptic  lint  or  gauze,  the  end  of  which 
is  carried  through  the  perforation  in  the  parietes.  Murphy,  in 
a  successful  case,  employed  suture  alone. 

Wounds  of  the  spleen  cause  death,  according  to  Edler,  almost 
invariably  by  haemorrhage.  Of  uncomplicated  cases,  65  per  cent, 
died  ;  of  all  cases,  83.3  per  cent.  Suppuration  is  rare,  and  then 
mostly  from  the  presence  of  foreign  matter.  The  friability  of 
the  splenic  tissue  renders  closure  of  a  gaping  wound,  so  as  to 
check  haemorrhage,  difficult.  Parkes,  however,  found  that  deeply 
placed  sutures  of  catgut  held  fairly  well.  If  the  suture  fails, 
plugging  with  lint  or  gauze  must  be  employed.  Should  these 
measures  fail,  the  organ  must  be  removed.  In  all  cases  of 
serious  injury  to  the  spleen,  primary  removal  is  indicated  ;  the 
results  of  removal  for  injury  are  far  more  favourable  than  for 
disease. 

Shot-wounds  of  the  kidney  are  not  so  dangerous  as  is  gener- 
ally supposed.  According  to  Edler,  death  most  frequently  results 
from  pyaemia,  accompanied  with  peritonitis  and  suppuration. 
Recovery  is  usually  very  tedious,  on  account  of  the  frequent 
complication  of  urinary  extravasation.  Of  uncomplicated  shot- 
wounds  of  the  kidney,  85  per  cent.,  according  to  Edler,  get  well; 
of  compHcated  cases,  only  16  per  cent.;  and  of  all  cases,  56  per 
cent,  recover.  If  only  15  per  cent,  of  cases  of  uncomplicated 
shot-wound  of  the  kidney  die,  it  is  doubtful  whether  operation 
is  ever  indicated  in  this  class,  except  on  undoubted  signs  of 
haemorrhage  or  peri-nephric  or  peritoneal  suppuration.  The 
complications  of  renal  injuries  are  likety  to  be  severe — on  the 
right  side,  wounds  of  liver  and  colon ;  on  the  left  side,  wounds  of 
spleen  and  colon — and  the  results  of  operations  are  therefore 
not  likely  to  be  favourable.  In  cases  of  doubt  as  to  the  wisdom 
of  removing  the  whole  organ,  or  of  the  ability  of  the  patient  to 
bear   the   operation,  the   chances  of  successful    issue    may  be 


714  GUNSHOT   WOUNDS. 

increased  by  free  drainage  carried  out  through  a  wound  made 
in  the  loin.  In  some  cases  bullets  have  been  found  embedded 
in  the  renal  tissue. 

Wounds  of  the  urinary  bladder  are  closed  by  Lembert's 
suture  in  the  same  way  as  wounds  of  the  other  hollow  viscera. 
The  whole  subject  of  cystorraphy  will  be  more  thoroughly 
dealt  with  under  the  head  of  intra-abdominal  rupture  of  that 
viscus. 

Wounds  of  the  gall-bladder  are  easily  diagnosed  from  the 
presence  of  bile  in  the  cavity.  If  the  wound  involves  only  the 
fundus,  and  is  not  large  or  lacerated,  it  may  be  closed  at  once 
by  suture.  If  the  wound  traverses  both  sides  of  the  bladder 
and  the  liver  as  well,  then  it  may  be  best  to  remove  the  whole 
viscus.  To  reach  the  upper  wound,  it  would  be  necessary  to 
partly  detach  the  bladder  from  the  liver,  and  this  detachment 
would  predispose  to  gangrene.  Therefore,  in  such  a  case, 
cholecystectomy  would  be  the  safest  procedure. 

Supposing  now  that  the  whole  of  the  visceral  wounds  have 
been  satisfactorily  dealt  with,  and  that  the  parts  are  in  a  con- 
dition in  which  repair  is  possible,  a  final  cleansing  of  the  cavity 
is  carried  out,  and  the  wound  is  closed,  with  or  without  drainage 
as  seems  best.  A  larger  nozzle  may  be  put  on  to  the  irrigating 
tube,  and  the  reservoir  is  elevated  a  foot  or  two  higher,  so  that 
a  larger  and  more  rapid  stream  is  conveyed  inside  the  abdomen. 
While  the  fingers  move  the  intestines  about,  the  stream  is  con- 
ducted successively  to  all  parts  of  the  cavity,  and  is  not  checked 
till  it  returns  as  clear  as  it  went  in.  Then  all  superfluous  fluid 
is  pressed  out,  and  a  few  large  sponges  with  sponge-holders 
attached  are  placed  in  the  abdominal  hollows,  and  left 
there  while  the  stitches  are  inserted.  They  are  removed, 
with  any  free  fluid  that  has  been  left,  before  the  stitches  are 
tied. 

In  some  cases  the  state  of  the  patient  may  be  so  grave  that 
resection,  or  any  prolonged  operation  of  suturing,  may  not  be 
permissible.  In  such  cases  the  wounded  bowel,  resected  or 
not  as  may  seem  best,  is  fixed  in  the  wound,  so  as  to  produce 


STAB    WOUNDS.  715 

an  artificial  anus.  Temporary  closure  of  the  intestinal  wounds 
in  the  parietal  opening  may  always  be  carried  out,  so  that 
the  peritoneal  cavity  may  be  sealed  off  by  plastic  exuda- 
tions before  the  artificial  anus  is  made.  This  proceeding  is 
carried  out  in  the  manner  already  described  for  enterotomy 
and   enterectomy. 


OPERATION    FOR    STAB-WOUNDS    OF   THE    ABDOMEN. 

The  whole  subject  of  stab-wounds  being  in  many  respects 
similar  to  that  of  shot-wounds  of  the  abdomen,  it  will  be  un- 
necessary to  do  more  than  specify  the  points  of  difference. 

Here  again  we  are  indebted  to  Morton,'''  MacCormac,*  and 
Gaston*  for  drawing  up  tables  of  recorded  cases  of  operations. 
Morton  collected  ig  cases,  including  one  by  a  splinter  of 
wood;  of  these,  12  recovered.  MacCormac  gives  18  cases,  with 
10  recoveries.  Gaston's  table,  which  most  nearly  brings  the 
operations  up  to  date,  contains  28  cases,  with  16  recoveries: 
19  cases  had  wounds  involving  one  or  more  of  the  viscera; 
of  this  number,  10  recovered  and  9  died.  Morton's  most  recent 
statistics  (1889)  give  79  cases,  with  48  recoveries — a  mortality  of 
39.24  per  cent.  This  must  be  regarded  as  a  very  satisfactory 
mortality,  considering  the  nature  of  the  injuries. 

Any  sharp  instrument  forced  through  the  parietes  may 
perforate  hollow  viscera.  But  the  effects  vary  widely,  according 
to  the  nature  of  the  instrument.  A  stab  with  a  bodkin  or  a 
stiletto  has  very  different  immediate  results  from  a  deep  gash 
with  a  large  broad-bladed  sword.  But  the  ultimate  results  may 
be  the  same.  I  have  seen  death  take  place  in  five  days  from 
suppurative  peritonitis,  caused  by  puncture  of  the  intestine  by 
a  fine  exploring  needle  ;  and  I  have  known  of  another  case  in 
which  a  triple  wound  in  the  intestinal  coats,  as  broad  as  the 
jack-knife  which  caused  it,  was  not  fatal  in  so  short  a  time. 
In  a  large  wound  there  may  be  protrusion  of  viscera — an  accident 
which  may  sometimes  be  fortunate,  as  exposing  an  intestinal 

*  Loc.  cit. 


716  STAB    WOUNDS. 

wound,  and  permitting,  to  some  extent  at  least,  escape  of  its 
contents  outside  the  abdomen.  Every  variety  of  wound  may  be 
caused  by  a  diversity  of  instruments.  A  jagged  piece  of  wood, 
the  spike  of  a  railing,  or  the  prongs  of  a  pitchfork,  will  each 
have  its  variety  of  wound,  partially  to  be  inferred  from  the 
character  of  the  instrument. 

Now,  it  has  been  found  that  stabbing  wounds  are  by  no 
means  so  uniformly  fatal  as  perforations  caused  by  bullets.  The 
danger  would  seem,  in  such  cases,  to  depend  as  much  on  the 
condition  of  the  viscus  as  to  fulness  or  emptiness,  as  on  the 
amount  of  injury  it  has  received.  Through  a  wound  of  fair  size, 
a  viscus  distended  with  fluid  will  at  once  empty  itself  into  the 
peritoneum  ;  and,  further,  a  distended  viscus  is  more  liable  to 
be  ruptured  than  an  empty  one.  The  rapidly-moving  bullet 
goes  straight  through  everything,  full  or  empty  ;  while  the  com- 
paratively slow-moving  instrument,  pushed  by  hand  or  pene- 
trating after  a  fall,  will  push  an  empty  viscus  aside. 

The  conditions  vary  according  to  the  organ  penetrated,  just 
as  they  do  in  gunshot  wounds.  Cutting  wounds  have  more 
blood  effused,  and  death  from  haemorrhage  is  more  common  in 
them  than  in  other  penetrating  wounds. 

Looking  at  the  recorded  cases  of  operation,  we  find  that  in 
several  the  manipulations  included  nothing  more  than  cleansing 
of  the  abdominal  cavity  from  blood-clot  and  suturing  of  the 
parietal  wound.  In  Carson's  case,  a  liver-wound  was  sutured, 
and  death  took  place  on  the  fifth  day  from  iodoform  poisoning ; 
the  peritoneal  cavity  being  found  very  nearly  normal.  In  two 
cases  excision  of  intestine  had  to  be  carried  out :  one  died  and 
one  recovered.  In  nine  cases  suture  of  intestine  or  stomach  was 
carried  out :  in  one  the  spleen  was  excised ;  and  in  several 
various  wounds  of  omentum,  mesentery  and  other  parts  had  to 
be  dealt  with. 

Resection  of  the  margins  of  the  wound  is  not  called  for  so 
frequently  after  stabbing  as  after  gunshot  injuries.  In  a  clean- 
cut  wound,  simple  suture  without  much  inversion  of  margins 
will  be  efficient.  Bleeding,  being  a  more  frequent  and  a  more 
dangerous    result    of    stab -wounds,    requires    correspondingly 


AFTER-TREATMENT.  717 

minute  attention.  In  a  greater  number  of  cases  than  after  shot- 
wounds,  operation  may  be  successfully  carried  out  through  the 
original  stab-wound  enlarged  in  whatever  direction  is  most 
convenient. 

As  to  indications  for  operation  in  stab-wounds  of  the 
abdomen,  there  is  a  very  general  consensus  of  opinion  that  every 
case  of  undoubted  penetration  of  the  abdomen  should  be  at  once 
treated  by  laparotomy.  The  indication  is  only  a  little  the  less 
urgent  if  there  is  no  perforation  of  viscera ;  cleansing  of  the 
cavity  from  blood-clot,  and  checking  haemorrhage,  put  the  patient 
in  a  far  more  favourable  condition  for  recovery  than  when  these 
operations  are  not  carried  out.  In  any  case,  perforation  of  viscera 
cannot  certainly  be  diagnosed  till  abdominal  section  has  been 
performed. 


AFTER-TREATMENT  OF  OPERATIONS  FOR  GUN-SHOT  AND  STAB  WOUNDS 
OF    THE    ABDOMEN. 

The  first  principle  in  the  treatment  of  these  cases  is  intestinal 
rest.  If  there  are  wounds  of  the  stomach  or  upper  portion  of 
the  small  bowel,  all  food  by  the  mouth  must  be  withheld  for 
from  four  to  six  days,  and  rectal  feeding  instituted.  The  first 
foods  given  by  the  mouth  should  be  either  dilute  peptones  or 
beef  jellies,  or  peptonised  milk.  The  patient  should  be  kept  as 
quiet  as  possible  in  bed  ;  change  of  position  should  be  made  by 
extraneous  help,  and  not  by  personal  muscular  effort.  If  opium 
is  to  be  recommended  anywhere  in  abdominal  surgery,  it  should 
be  in  such  cases  as  these  which  are  frequently  attended  with 
considerable  mental  disturbance.  It  should  be  given  as  morphia, 
and  by  hypodermic  injection. 

When  drainage  has  been  employed  either  for  incipient 
peritonitis  or  for  a  very  abundant  extravasation  of  intestinal 
contents,  the  management  of  the  tube  will  demand  considerable 
care  and  judgment.  At  frequent  and  stated  intervals  the  cavity 
is  emptied  by  the  exhausting  syringe,  and  the  nature  of  the 
discharge  observed.     On  the  slightest  evidence  of  the  oncome  of 


718  SHOT  AND   STAB   WOUNDS. 

suppurative  peritonitis,  irrigation  with  a  mild  antiseptic  (I  should 
select  boro-glyceride)  should  be  carried  out,  and  some  of  the 
fluid  should  be  permitted  to  remain  inside  the  cavity.  The 
formation  of  intestinal  adhesions,  which  is  one  of  the  chief 
dangers  in  acute  peritonitis,  is  not  so  likely  to  occur  if  the 
intestines  are  kept  floating  in  a  mild  watery  fluid ;  and  the  risks 
of  septic  absorption  are  lessened  by  the  presence  of  an  antiseptic 
in  the  cavity.  The  irrigating  process  may  be  repeated  with 
advantage  every  few  hours.  With  a  little  judgment  in  the 
arrangement  of  the  contrivances,  it  is  possible  to  employ  irrigation 
without  disturbing  the  patient  or  soiling  the  bed-clothing.  In 
such  cases  stimulants  in  small  quantities  may  be  added  to  the 
nourishing  enemas,  and  the  use  of  the  rectal  tube  and  the  hot- 
water  enema  for  the  removal  of  gas  may  be  called  for. 

If  acute  peritonitis  develops  soon  after  operation,  and  no 
drainage  tube  has  been  inserted,  the  best  treatment  will  in  most 
cases  be  to  at  once  insert  the  tube  and  commence  irrigation  with 
hot  (105° — 110°)  antiseptic  fluids.  Several  authorities  in  such 
cases  recommend  the  employment  of  considerable  doses  of 
atropia  alone,  or  combined  with  morphia.  I  should  place  more 
v.alue  on  free  stimulation  by  the  rectum,  frequent  turpentine 
enemas  and  the  use  of  the  rectum  tube.  The  employment  of 
leeching  in  the  earlier  stages  has  been  highly  spoken  of,  and 
Leiter's  cold-water  tin  coil  is  said  to  have  given  good  results. 

The  parietal  wound  is  treated  exactly  as  in  other  abdominal 
operations. 


Rupture  of  the  Intestine. 

Although  only  a  very  few  operations  have  been  performed 
for  this  condition,  its  extreme  importance  and  the  preparedness 
of  surgery  to  deal  with  it  will  justify  a  somewhat  detailed  con- 
sideration. Our  knowledge  of  the  whole  subject  has  recently 
been  much  advanced  by  the  publication  of  a  prize  essay  on 
"  Contusion  of  the- Abdomen,  with  Rupture  of  the  Intestine,"  by 
B.  F.  Curtis  of  New  York,"^'  which  is  founded  upon  numerous 
experiments,  and  a  careful  and  analytical  study  of  ii6  cases  of 
recorded  rupture  of  the  intestines.  MacCormacf  has  collected 
13  cases  of  operation  for  rupture  of  the  intestine,  simple  and 
complicated,  thus  far  without  a  single  success.  The  case  of 
Croft  of  St.  Thomas's  Hospital  recovered  from  the  immediate 
effects  of  the  operation,  but  died  from  the  effects  of  a  second 
operation  performed  a  month  later  for  the  cure  of  the  artificial 
anus  which  remained. 

Pathological  Anatomy. — As  a  result  of  his  experiments,  Curtis 
came  to  the  conclusion  that  the  injur}^  is  not  a  true  rupture, 
a  bursting  of  the  gut  over  its  contents,  but  a  contused  and 
lacerated  wound  made  by  crushing  between  the  contusing  body 
and  the  bony  parts.  The  danger  of  rupture  was  diminished  by 
partial  distension  of  the  gut.  The  possibility  of  rupture  from 
forcible  impaction  of  the  liquid  contents  against  a  fixed  loop  of 
bowel  must  not,  however,  be  overlooked.  Rapture  of  the 
duodenum  would  seem  to  take  place  in  this  way.  I  have  seen 
two  cases  of  rupture  of  the  duodenum,  caused,  in  one  instancCj 
by  a  fall  on  the  back,  and  in  another  by  a  severe  blow  on  the 
back ;  in  neither  was  there  fracture  of  spine,  nor  any  injur}^  in 
front. 

The  most  common  cause  of  the  injury  — in  about  28  per  cent. 
of  all  the  cases — was  found  by  Curtis  to  be  the  kick  of  a  horse 
or  a  man.  Next  to  this,  and  in  about  equal  proportions,  are 
'  Internat.  Journ.  Med.  Sc.     Oct.,  1887.  t  Op.  cit. 


720  RUPTURE   OF   THE  INTESTINE. 

run-over  accidents,  blows  on  the  belly  by  weights,  and  falls  on 
projecting  points.  Great  velocity  and  small  area  of  striking 
surfaces  would  seem  to  be  most  likely  to  cause  rupture.  In 
113  cases,  the  relative  frequency  of  parts  injured  was: — 
duodenum,  6  cases ;  jejunum,  44 ;  ileum,  38 ;  other  portions  of 
the  small  intestine,  21 ;  and  colon,  4.  The  danger  of  rupture 
was  found  to  be  greatest  in  those  parts  of  the  intestine  which 
are  most  fixed,  excluding  the  large  intestine  on  account  of  its 
being  sheltered. 

The  extent  of  the  rupture  varies  considerably.  In  about  a 
fifth  of  the  cases  the  rupture  extended  either  completely,  or 
almost  completely,  across  the  bowel.  In  a  tenth  of  the  cases, 
the  ruptures  were  multiple.  The  size  of  rent  most  frequently 
observed  was  about  an  inch  in  length.  There  is  a  somewhat 
uncertain  relation  between  the  extent  of  injury  and  the  violence 
of  the  blow,  the  more  extensive  injuries  being  caused  by  the 
more  violent  blows.  This,  however,  in  no  way  influences  prog- 
nosis ;  for  small  ruptures  are  as  certainly  fatal  as  large  ones. 
The  mucous  membrane,  in  the  large  majority  of  cases,  was 
found  everted  and  bulging  through  the  peritoneal  rupture. 

Extravasation  of  intestinal  contents  is  almost  invariably 
found.  Faecal  fluids  were  found  in  two-thirds  of  all  Curtis's 
cases ;  and  the  existence  of  peritonitis  in  nearly  all  the  others, 
rendered  it  probable  that  extravasation  of  contents  had  taken 
place  in  these  also.  In  two  cases  of  complete  rupture,  the  open 
ends  were  so  entirely  closed  by  muscular  contraction,  prolapse 
of  the  mucous  membrane,  and  rapidly  formed  adhesions,  that 
the  bowel  was  actually  found  to  be  distended  above  the  seat 
of  rupture.  In  some  of  the  cases,  contusions  of  the  gut  were 
found,  in  addition  to  the  rupture. 

The  most  serious  complication  is  injury,  either  as  laceration 
or  as  contusion,  to  the  mesentery.  A  laceration  of  the  mesen- 
tery may  cause  death  in  a  few  minutes  from  haemorrhage ;  and 
contusion,  followed  by  haemostasis  in  its  vessels,  may  result  in 
gangrene  of  the  bowel.  In  16  per  cent,  of  Curtis's  cases  there 
was  either  laceration  or  contusion  of  the  mesentery,  and  these 
were   among  the  most    rapidly  fatal  of  all.      Of   15   cases  of 


SYMPTOMS.  721 

laceration  of  the  mesentery,  ail  but  three  were  fatal  within 
twenty-four  hours.  The  importance  of  these  observations,  from 
a  practical  point  of  view,  is  self-evident. 

Symptoms. — The  symptoms  may  be  conveniently  considered 
as  those  immediately  following  the  injury  and  those  occurring 
subsequently.  The  symptoms  first  observed  are  usually  shock, 
restlessness,  nausea  and  vomiting,  retention  of  urine,  consti- 
pation, and  local  pain  and  tenderness.  In  the  great  majority  of 
cases,  shock  is  present  in  a  marked  degree.  In  a  few,  however, 
it  is  described  as  absent.  A  certain  amount  of  restlessness  is 
usually  noted  in  the  early  stages,  but  a  great  many  cases  do  not 
exhibit  this  symptom  at  all.  Vomiting  in  the  early  stage  is  one 
of  the  most  constant  of  the  symptoms,  and  where  there  is  no 
vomiting  there  is  usually  nausea.  In  a  few  cases,  blood  is 
mingled  with  the  vomit.  In  most,  the  vomit  is  simply  the 
contents  of  the  stomach,  which,  as  time  passes,  show  a  com- 
mingling with  bile.  If  the  patient  lives  long  enough,  the 
vomit  may  become  faecal ;  but  this  is  usually  a  concomitant  of 
developed  peritonitis.  Urinary  retention  is  present  in  about 
half  the  cases.  No  doubt  this  is  part  of  the  general  condition 
of  abdominal  shock.  Pain  is  present  almost  universally.  It  is 
nearly  always  of  a  severe  character,  and  variously  described  as 
twisting,  lancinating,  burning,  or  griping.  It  comes  on  in 
gusts,  and  occasionally  remits  or  intermits.  Tenderness  on 
palpation  is  nearly  always  complained  of  at  the  outset ;  later 
on,  when  inflammation  supervenes,  it  is  a  constant  and  marked 
symptom. 

Distension  of  the  abdomen  comes  on  soon,  and  is  marked 
according  to  the  duration  of  the  case.  In  the  later  stage,  when 
peritonitis  is  fully  developed,  distension  becomes  drum-like,  and 
the  abdom.en  is  tense  and  hard.  With  this  distension  tympanitic 
resonance  is  always  present.  One  feature  of  this  resonance  is 
sometimes  described  as  a  disappearance  of  the  dulness  over  the 
site  of  the  liver.  It  would  seem,  however,  that  this  symptom  is 
a  very  variable  and  uncertain  one.  It  is  caused  by  the  escape 
of  gas  from  the  intestine  into  the  general  cavity,  and  must  take 

47 


722  RUPTURE  OF  THE  INTESTINE. 

place  in  the  early  stages  before  adhesions  have  formed  to  limit 
its  dffusion. 

The  later  sj^mptoms  are  essentially  those  of  peritonitis.  The 
temperature,  as  is  usual  in  severe  cases  of  peritonitis,  may  not 
show  any  rise,  or  may  be  subnormal.  In  most  cases,  however, 
there  is  a  moderate  rise  of  temperature,  which  takes  place  during 
the  first  twenty-four  hours. 

The  vomiting  becomes  faecal  some  time  during  the  second 
day:  constipation  is  then,  of  course,  alwa3^s  present.     In  fact 
the  whole  of  the  late  symptoms  are  identical  with  those  following 
peritoneal  suppuration. 

Curtis  distinguishes  three  sets  of  cases,  according  to  the 
symptoms  they  present.  In  the  first  set,  the  patient  never 
passes  out  of  the  condition  of  profound  shock,  and  rapidly  dies. 
In  these  cases  free  haemorrhage  usually  accompanies  the  injury  ; 
but  cases  with  abundant  faecal  extravasation  without  haemorrhage 
frequently  die  without  recovering  from  the  primary  collapse. 

The  second  set  includes  those  cases  in  which  local  pain  and 
tenderness  are  marked,  and  in  which  the  patient  rallies  to  an 
attack  of  acute  peritonitis. 

The  third  set  includes  those  in  which  there  are  no  very 
definite  symptoms  of  peritonitis,  but  which  keep  the  surgeon  in 
constant  apprehension  of  the  development  of  grave  conditions. 
The  patient  rallies  very  slowly,  and  then  passes,  by  imperceptible 
degrees,  into  a  condition  indicating  the  oncome  of  severe  peri- 
tonitis. 

Diagnosis. — The  diagnosis  will  be  assisted  by  a  consideration 
of  the  cause  which  produced  the  injury,  and  the  site  of  it.  A 
rupture  of  the  intestine  is  liable  to  be  confoimded  with  simple 
contusion  of  the  abdomen.  The  symptoms  of  contusion  are 
more  acute  at  first  than  those  of  rupture  ;  but  in  most  cases  the 
patient  soon  exhibits  signs  of  improvement.  Profound  and 
immediate  shock  is  probably  more  frequent  in  cases  of  simple 
contusion  than  in  cases  of  genuine  rupture.  Restlessness  is  not 
so  frequent  in  contusion  ;  vomiting  is  present  in  about  half  the 
cases.     Faecal  vomiting  is  never  observed.     Occasionally  blood 


OPERATIVE   TREATMENT.  723 

is  noticed  in  the  urine  and  in  the  stools.  Abdominal  distension 
is  not  so  marked,  and  tympanitic  resonance  is  rarely  observed. 
Dulness  on  percussion  has  been  noted  as  a  rare  symptom.  The 
symptoms  are  thus  very  similar  to  those  following  rupture  of 
the  intestine — only  they  are,  with  the  exception  of  the  primary 
shock,  less  acute,  and  they  do  not  last  so  long. 

Operative  Treatment.  —  The  prognosis  of  intestinal  rupture 
being  utterly  hopeless,  surgical  operation  gives  the  patient  the 
only  chance  of  life.  This  operation  should  be  performed  as 
early  as  possible.  The  average  duration  of  life  being  only 
forty-eight  hours,  and  the  condition  of  the  patient  becoming 
rapidly  worse  during  this  time,  it  is  evident  that  every  hour 
which  elapses  lessens  the  chance  of  a  successful  issue  to  opera- 
tion. The  whole  question  is  one  of  diagnosis ;  and  in  cases  of 
doubt  it  may  be  permissible  to  wait  while  symptoms  develop,  to 
show  that  it  is  not  a  case  of  simple  contusion. 

Occasionally  the  symptoms  point  clearly  to  haemorrhage, 
and  in  these  cases  it  may  be  justifiable  to  wait  while  means 
are  adopted  to  check  it.  Compression  of  the  abdomen  by 
bandages  over  a  firm  pillow  has  been  recommended  for  this 
purpose.  The  amount  of  success  which  is  likely  to  follow  such 
a  proceeding  is,  however,  very  uncertain.  In  every  case  the 
patient  is  kept  at  perfect  rest.  Examination  is  made  as  gently 
as  possible ;  unnecessary  manipulation  of  every  sort  must  be 
condemned.  Stimulating  enemas  ought  to  be  administered  if 
the  patient's  condition  demands  it.  Food  by  the  mouth  had 
better  be  withheld.  The  therapeutic  value  of  morphia  is 
doubtful :  as  masking  the  evolution  of  symptoms,  it  may  be 
harmful.  In  the  great  majority  of  cases,  however,  the  pain  is 
so  intense  that  the  administration  of  morphia  has  usually  been 
the  first  practical  step  in  the  treatment. 

The  incision  is  made  in  the  middle  line  ;  it  should  be  about 
four  inches  in  length,  and  the  middle  of  it  should  be  at  the 
umbilicus.  If  necessary,  the  incision  may  be  prolonged — 
upwards  or  downwards,  according  to  the  site  of  injury.  Before 
the  peritoneum  is  divided,  the  presence  of  blood  in  the  cavity 

47  * 


724  RUPTURE   OF  THE   INTESTINE. 

may  be  apparent.  If  gas  is  present,  it  will  rush  out  on  making 
the  opening.  Pus,  faeces,  or  intestinal  fluids  make  themselves 
evident  either  at  once  or  after  the  exploration  of  the  cavity. 
For  this  exploration  the  best  means  is,  probably,  at  first  to  pass 
the  sponge  on  a  sponge-holder  into  the  pelvis  and  the  lumbar 
hollows.  The  position  of  a  collection  of  extravasated  fluid  will 
frequentl}''  indicate  the  site  of  rupture.  Should  haemorrhage  be 
going  on,  the  bleeding  point  must  be  at  once  looked  for  and  the 
vessel  secured.  It  is  recommended,  if  the  bleeding  is  free,  that 
the  abdominal  aorta  and  the  root  of  the  mesentery  should  be 
compressed  while  the  bleeding  point  is  being  looked  for.  In 
such  a  case  it  will  usually  be  necessary  to  turn  the  whole  of  the 
intestines  outside  the  abdomen.  When  the  bleeding  vessel  has 
been  secured,  the  intestines  are  now  carefully  examined  for 
injuries.  Should  the  haemorrhage  have  proceeded  from  a  wound 
in  the  mesentery,  the  question  of  resection  of  the  bowel  will 
have  to  be  considered.  The  decision  will  depend  upon  the 
amount  of  injury  to  the  mesenteric  vessels,  and  the  condition  of 
the  gut  supplied  thereby.  In  most  cases  resection  of  the  intes- 
tine will  have  to  be  followed  by  the  formation  of  an  artificial 
anus  ;  for  the  patient  will  rarely  be  able  to  bear  complete  suture. 
Where  the  seat  of  injury  to  the  intestine  is  discovered  on  first 
inspection,  and  it  is  possible  to  suture  it  without  turning  the 
bowels  outside  the  cavity,  this  should  always  be  done.  In  every 
case  where  bowels  have  been  turned  outside,  we  should  endea- 
vour to  return  them  to  the  cavity  as  soon  as  possible  after 
the  injury  has  been  discovered.  It  is  unnecessary  to  keep  the 
whole  of  the  bowels  outside  while  the  rupture  is  being  closed ; 
and  it  has  been  found  in  experiments  that  shock  is  less  likely  to 
be  severe  if  the  intestines  are  returned  as  soon  as  possible  after 
the  injury  is  discovered. 

The  intestine  being  returned,  the  ruptured  portion  of  bowel 
is  brought  to  the  surface,  isolated  by  sponges  and  sponge-cloths, 
and  steps  are  taken  for  its  immediate  closure.  If  there  is  much 
shock,  it  will  be  wise,  at  this  stage,  to  start  irrigation  of  the 
abdominal  cavity  with  hot  lotion,  as  recommended  for  cases  of 
gunshot  wound.     In  any  case,  by  saving  time  in  the  removal  of 


OPERATIVE   TREATMENT.  725 

extravasated  fluid,  the  immediate  application  of  the  irrigator 
must  always  be  of  advantage.  In  looking  for  the  injured  bowel 
the  seat  of  the  blow  will  have  to  guide  us ;  but  it  must  not  be 
forgotten  that  the  intestine  may  slip  away  to  some  distance,  and 
also  that  the  injuries  are  occasionally  multiple ;  therefore  the 
examination  should  be  very  extensive  and  very  thorough. 

If  simple  suture  of  the  rent  is  likely  to  suffice,  this  is  carried 
out  in  the  manner  already  described  for  Enterorraphy.  If  there 
is  much  bruising  around  the  site  of  rupture,  resection,  total  or 
partial,  according  to  the  position  and  extent  of  the  wound,  must 
be  carried  out.  If  the  rupture  lies  on  the  free  margin  of  the 
bowel,  simple  excision  of  the  lips  of  the  contused  wound  will 
suffice  ;  if,  however,  it  lies  at  or  near  the  mesenteric  attachment, 
resection  of  the  whole  calibre  will  be  required.  Every  case 
must  be  judged  on  its  own  merits ;  it  is  impossible  to  lay  down 
general  laws  applicable  to  all  cases. 

As  a  matter  of  practice,  it  will  probably  appear  that  many 
cases  of  rupture  of  the  intestine  will  be  best  treated  by  the 
formation  of  an  artificial  anus.  Usually  the  operation  will  have 
to  be  performed  while  the  patient  is  in  a  most  unfavourable 
condition,  and  prolonged  manipulation  will  be  full  of  danger. 
The  quickest  operation  compatible  with  tiding  the  patient  over 
the  period  of  danger  will  probably  be,  in  the  long  run,  most 
successful.  It  may  turn  out  that  the  use  of  a  hot  irrigating 
fluid  inside  the  abdominal  cavity  will  considerably  improve  the 
patient's  condition ;  then  the  rupture  may  be  closed  while  irri- 
gation is  going  on. 

However,  as  these  ruptures  are  usually  short  and  will  rarely 
require  even  partial  resection,  their  closure  by  suture  may  be 
very  rapidly  effected.  Should  it  be  decided  to  conclude  by 
the  formation  of  an  artificial  anus,  the  ends  of  the  gut  are  fixed 
to  the  wound  by  means  of  ligatures  or  clamps,  and  left  there 
for  twenty-four  hours,  or  longer,  until  adhesions  form. 

The  employment  of  drainage  must  be  left  to  the  judgment 
of  the  surgeon.  In  most  cases  drainage  is  indicated,  both 
as  a  remedial  measure  for  giving  exit  to  peritoneal  secre- 
tion, and  as  a  precautionary  measure  by  providing  an  opening 


726  RUPTURE  OF  THE  INTESTINE. 

through  which   the   cavity  may  be  washed   should    peritonitis 
supervene. 

The  after-treatment  and  general  management  of  the  case  is 
the  same  as  for  penetrating  wounds. 

RUPTURE    OF    THE    STOMACH. 

Rupture  of  the  stomach  does  not  require  special  description. 
It  is  more  rare  than  rupture  of  the  intestine,  on  account  of  its 
smaller  size,  deeper  situation,  and  protection  by  the  ribs.  Rup- 
ture may  be  complete,  traversing  the  whole  of  the. coats;  or 
incomplete,  affecting  only  one  or  two.  Peritoneal  ruptures, 
according  to  Devergie,  occur  principally  at  the  lesser  curva- 
ture, and  are  usually  multiple.  The  same  condition  may  exist 
on  the  mucous  coat,  and  "it  is  remarkable  that  these  often  exist 
just  on  the  point  opposite  the  external  tear."  Occasionally  the 
mucous  lining  of  the  stomach  is  completely  detached,  and  hangs 
in  shreds  inside  the  stomachic  cavity. 

The  symptoms  are  very  similar  to  those  of  ruptured  intestine. 
The  treatment  requires  no  separate  description.  The  seat  of 
rupture,  if  it  lies  in  the  posterior  wall  of  the  stomach,  can  be 
reached  only  by  division  of  the  gastro-colic  omentum,  and  is 
dealt  with  in  the  same  manner  as  shot  or  stab- wounds  of  the 
same  part. 


Rupture  of  the  Urinary  Bladder. 

Although  Laparotomy  for  this  condition  is,  comparatively 
speaking,  a  new  operation,  it  has  been  in  men's  minds  for  many 
years.  Benjamin  Bell  proposed  suture  of  the  bladder  for  rup- 
ture in  1789.  Blundell  of  Guy's  Hospital,  in  1824,  wrote  as 
follows :  "  Should  the  bladder  give  way  in  the  peritoneal  sack, 
why  should  we  not  lay  open  the  abdomen,  tie  up  the  bladder, 
discharge  the  urine,  and  wash  out  the  peritoneum  thoroughly 
by  an  injection  of  warm  water?  "  Blundell  fortified  his  sugges- 
tion by  numerous  experiments ;  and  Grandchamps,  about  this 
time,  performed  similar  experiments  with  the  same  end  in  view. 
A  good  many  surgeons  since  then  have  advocated  suture  of  the 
bladder  for  rupture ;  among  them  have  been  mentioned  Larrey, 
Gross,  and  Cusack.  Holmes,  among  modern  surgeons,  has 
perhaps  been  most  outspoken  in  his  recommendation  of  the 
operation.  Heath  and  Willett  were  the  first  to  perform  the 
operation  in  England. 

MacCormac  has  collected  reports  of  16  operations  :  of  these, 
six  recovered,  two  of  the  recoveries  being  cases  of  MacCormac's 
own.  I  have  seen  records  of  six  more  cases,  with  three  re- 
coveries and  three  deaths.  Norton  has  collected  27  operations, 
giving  10  recoveries  and  17  deaths,  a  mortality  of  62.9  per  cent. 
The  mortality  after  operation  will  always  be  high ;  but,  con- 
sidering the  almost  necessarily  fatal  termination  without  opera- 
tion, a  very  high  mortality  would  not  be  a  contra-indication. 

Pathological  Atiatomy, — A  knowledge  of  the  pathology  of  rup- 
tured bladder  has  been  greatly  advanced  by  the  monograph  of 
Walter  Rivington.  He  has  collected  a  total  of  322  cases  of 
rupture  of  the  bladder.  Of  these,  152  were  simple  fatal  intra- 
peritoneal ruptures ;  30  complicated  fatal  ruptures ;  90  extra- 
peritoneal ruptures,  simple  and  complicated ;  and  5  in  which 
the  position  was  uncertain.  The  simple  intra-peritoneal  rupture 
is  the  most  common,  extra-peritoneal   being  more  often  asso- 


728  RUPTURE   OF  THE    URINARY  BLADDER. 

ciated  with  fracture  of  the  pelvic  bones.  Of  288  cases,  240 
were  males  and  48  females. 

He  found  that  rupture  occurred  most  frequently  in  the  prime 
of  life,  in  persons  between  twenty  and  forty  years  of  age.  The 
period  of  survival  after  injury  was  longer  in  extra-peritoneal 
rupture  than  in  intra-peritoneal. 

The  causes  may  be  divided  into  predisposing  and  acute* 
Among  the  former,  distension  of  the  viscus  must  be  regarded 
as  the  most  potent ;  indeed,  it  v/ould  seem  to  be  almost  essen- 
tial for  the  simple  intra-peritoneal  rupture  to  take  place  that  the 
bladder  should  be  full.  This  does  not  hold  true  for  cases  of 
extra-peritoneal  rupture. 

Another  predisposing  cause  is  drunkenness.  In  a  very  large 
proportion  of  the  cases,  the  patient  has  been  described  as  pro- 
foundly or  partially  intoxicated.  In  such  cases  the  bladder  is 
usually  full,  sensibility  is  blunted,  and  the  individual  will  prob- 
ably have  been  indulging  in  horse-play  with  companions.  Under 
these  circumstances,  it  frequently  happens  that  an  exact  account 
of  the  mode  in  which  the  injury  was  produced  cannot  be 
obtained. 

The  acute  or  determining  causes  are  divided  by  Houei  into 
idiopathic  and  traumatic,  the  large  majority  being  idiopathic. 
The  usual  traumatic  cause  is  a  sharp  blow  of  some  weight 
inflicted  on  the  lower  part  of  the  abdomen.  Kicks,  blows 
received  in  fighting,  treading  on  the  prostrate  individual,  bodies 
falling  on  the  abdomen,  sharp  collision  with  prominent  objects, 
are  described  in  the  category  of  causes.  A  few  cases  of  simple 
concussion  have  been  described  as  causing  the  rupture. 

Of  idiopathic  causes,  by  far  the  most  common  is  excessive 
muscular  action,  combined  with  over-distension  of  the  bladder. 
A  few  cases  of  simple  rupture  of  the  bladder  from  over-disten- 
sion have  been  described.  Houel  denies  that  spontaneous 
rupture  from  over-distension  can  occur  in  the  normal  bladder. 
It  would  appear,  however,  that  there  is  no  doubt  that  this  does 
occasionally  occur.  Frequently  the  injury  is  predisposed  to  by 
the  existence  of  so-called  tunicary  hernia.;  that  is  to  say,  where 
the  muscular  fibres  become  separated,  so  as  to  leave  a  gap  in 


SYMPTOMS.  729 

the  continuity  of  the  bladder-walls,  and  thus  permit  a  local 
over-distension,  which  is  afterwards  easily  converted  into  a 
complete  rupture. 

It  would  seem  that  such  spontaneous  ruptures  are,  in  about 
an  equal  proportion  of  cases,  extra-peritoneal  and  intra-peri- 
toneal. 

As  to  the  possibility  of  rupture  taking  place  through  exces- 
sive muscular  action  on  an  over-distended  bladder,  there  can  be 
no  dispute.  Lifting  heavy  weights ;  struggling  during  the  ad- 
ministration of  ether ;  straining  at  stool ;  and  straining  efforts 
at  micturition,  are  described  amongst  the  active  causes  of  rup- 
ture from  muscular  action. 

In  the  female,  over-distension  and  rupture  have  been  caused 
by  retroversion  of  the  gravid  uterus. 

In  most  cases  the  rupture  is  on  the  posterior  surface  of  the 
bladder,  and  is  usually  between  one  and  two  inches  in  length. 
Other  positions,  lateral,  superior,  and  deep,  are  described ;  and 
lengths  of  tear,  varying  from  a  quarter  of  an  inch  to  three 
inches,  have  been  met  with. 

Symptoms. — The  symptoms  are  frequently  masked  by  the 
intoxicated  condition  of  the  patient.  He  may  be  unaware  of 
the  occurrence  of  any  injury,  and  hours  may  elapse  before  the 
gravity  of  his  position  is  discovered. 

Occasionally  he  exhibits  no  shock  whatever,  and  is  able  to 
walk  some  distance.  In  a  surprisingly  large  number  of  cases 
the  patient  has  been  able  to  walk  a  considerable  distance  with- 
out any  appearance  of  illness,  and  serious  symptoms  have  come 
on  as  late  as  twenty-four  hours  after  the  infliction  of  the  injury. 

If  the  patient  is  sober,  or  only  slightly  intoxicated,  intense 
pain  is  usually  complained  of  at  the  moment  of  injury.  Very 
soon  faintness,  sickness,  and  profound  collapse  supervene.  In 
a  few  cases  there  has  been  a  sensation  as  of  something  bursting 
inside  the  abdomen.  The  patient  usually  staggers  and  falls, 
and  is  unable  to  raise  himself  up  or  stand  without  support.  If 
he  is  able  to  walk,  he  is  doubled  up,  and  leans  upon  any  object 
he  can  grasp. 


730  RUPTURE   OF   THE    URINARY  BLADDER. 

Usually  the  shock  temporarily  abates,  the  pain  diminishes 
and  the  patient  describes  himself  as  feeling  better.  Very  soon, 
however,  an  urgent  desire  to  pass  water  comes  on ;  but  the 
patient  on  attempting  to  do  so  finds  that  it  is  impossible. 
Repeated  attempts  are  followed  by  the  passage  of  only  a  few 
drops  of  blood  or  bloody  urine.  Along  with  much  tenesmus, 
there  is  acute  pain  in  the  hypogastric  and  umbilical  regions, 
which  is  aggravated  by  the  erect  posture.  The  countenance 
becomes  pallid  and  anxious  and  pinched ;  restlessness,  nausea, 
vomiting,  and  thirst,  with  great  constitutional  disturbance,  and 
quick,  small,  and  irregular  pulse,  now  appear,  and  the  gravity  of 
the  case  is  evident.  The  patient  by  this  time  will  have  sought 
for  medical  relief,  and  the  surgeon  will  usually  pass  the  catheter. 
Only  blood  or  blood  and  urine  escape  in  drops,  and  the  patient 
gets  no  relief.  The  catheter,  in  passing,  either  enters  with  great 
ease,  passing  upwards  for  an  abnormal  distance,  or  it  is  checked 
near  the  neck  of  the  bladder,  and  it  is  found  impossible  either 
to  rotate  the  instrument  or  to  depress  it  between  the  patient's 
thighs.  These  different  conditions  depend  on  whether  the 
catheter  passes  through  the  rent  in  the  bladder,  or  impinges 
against  the  walls  of  the  collapsed  viscus.  Should  the  point  of 
the  catheter  enter  the  peritoneal  cavity,  it  may  be  moved  about 
in  all  directions,  and  its  point  may  be  felt  with  abnormal  dis- 
tinctness through  the  parietes.  In  such  a  case  there  can  be  no 
doubt  as  to  the  existence  of  rupture  of  the  bladder.  In  cases 
of  doubt,  before  removing  the  catheter  a  measured  quantity  of 
warm  antiseptic  lotion — say,  about  eight  ounces — should  be 
injected  through  the  catheter.  The  use  of  the  rectal  bag,  by 
pushing  the  viscus  forwards  against  the  parietes,  will  here  be 
found  of  advantage.  While  the  fluid  is  being  injected,  the 
supra-pubic  region  should  be  percussed  for  evidence  of  in- 
creased dulness.  When  the  full  quantity,  has  been  injected,  the 
fluid  is  permitted  to  flow  out.  If  there  is  rupture,  only  a  portion 
of  the  fluid  will  come  away ;  if  there  is  no  rupture,  the  whole  of 
it  will  be  collected. 

In  cases  of  extra-peritoneal  rupture,  the  symptoms  are  not 
so  severe ;  shock  is  not  so  great ;  and  symptoms  of  peritoneal 


OPERATIVE   TREATMENT.  731 

inflammation  do  not  come  on  so  rapidly,  and  are  not  so 
severe. 

In  cases  of  complete  intra-peritoneal  rupture,  symptoms  of 
peritonitis  very  quickly  appear,  with  abdominal  tenderness  and 
distension,  sickness  and  vomiting,  feeble,  irregular,  and  rapid 
pulse,  and  hurried  thoracic  respiration.  The  patient  is  tor- 
mented with  a  strong  desire  to  pass  water,  and  makes  frequent 
but  ineffectual  efforts  to  do  so.  Pain  is  usually  severe,  some- 
times agonising. 

In  making  the  diagnosis,  it  is  important  to  find  out  whether 
the  bladder  was  full  at  the  time  of  the  accident.  Many  cases  of 
haematuria,  depending  upon  simple  contusion  of  the  bladder, 
are  attended  with  symptoms  of  collapse,  depending  usually  on 
serous  injuries  of  another  sort.  In  all  cases  of  abdominal  injury 
it  must  be  noted  that  secretion  of  urine  is  liable  to  be  diminished 
or  even  suppressed.  In  any  case  of  doubt,  the  rapid  aggrava- 
tion of  the  symptoms  and  the  increasing  gravit}^  of  the  patient's 
condi4;ion  will  help  to  clear  up  the  diagnosis. 

Operative  Treatment. — It  is  now  universally  admitted  that,  on 
the  diagnosis  of  intra-peritoneal  rupture  of  the  bladder,  opera- 
tion should  be  immediately  performed,  and  that  the  best 
operation  is  abdominal  section  and  suture  of  the  rent  in  the 
bladder.  The  sooner  the  operation  is  performed,  the  better. 
The  chances  of  recovery  are  greatly  diminished  after  twenty- 
four  hours  have  passed,  although  a  few  cases  of  recovery  after 
operation  later  than  this  have  been  recorded. 

The  technique  of  the  operation  is  of  the  simplest  possible 
description.  An  incision  is  made  in  the  middle  line  immediately 
above  the  pubes,  and  the  cavity  entered  in  the  ordinary  way. 
The  lower  end  of  the  incision  may  have  to  be  carried  down  to 
the  pubes. 

The  existence  of  rupture  will  usually  be  signalised  by  the 
escape  of  blood-stained  urine  mixed  with  serum.  Should  the 
recti  muscles  be  very  tense,  part  of  their  insertion  into  the 
pubes  may  be  divided,  and  the  size  of  the  opening  may  be 
further  increased  by  the  use  of  suitable  retractors.    The  incision 


732  RUPTURE  OF  THE    URINARY  BLADDER. 

will  usually  require  to  be  a  long  one,  as  it  happens  that  a 
majority  of  the  patients  are  stout  or  powerful  men. 

The  posterior  surface  of  the  bladder  is  exposed  as  fully  as 
possible  by  pushing  the  intestines  upward  into  the  cavity,  and 
keeping  them  there  by  means  of  sponges  of  suitable  size  and 
shape.  The  position  of  the  rent  will,  as  already  remarked,  be 
usually  found  on  the  posterior  surface  midway  between  the 
summit  and  the  base  of  the  bladder.  Should  it  lie  low  down, 
it  will  be  found  that  the  rectal  bag  will  materially  assist  subse- 
quent proceedings  by  elevating  the  field  of  operation. 

We  now  proceed  to  close  the  rent  in  the  bladder.  Should 
the  rent  lie  low  down,  this  may  be  a  proceeding  of  considerable 
difficulty.  MacCormac  found  that  transverse  incisions  made  on 
each  side  through  the  peritoneum  liberated  the  bladder,  and 
permitted  it  to  be  raised  up  higher  towards  the  surface. 

Various  methods  of  suturing  the  bladder  are  in  vogue.  For 
intra-peritoneal  rupture  Lembert's  suture  is  probably  the  best. 
MacCormac  used  it  in  his  two  successful  cases.  Dr.  A.  Brenner, 
an  assistant  in  Billroth's  clinic,  has  been  experimenting  on 
dogs,  with  a  view  to  discover  the  best  mode  of  suture  for  closing 
wounds  of  the  bladder.  The  variety  he  recommends  is  a  sort 
of  purse-string  suture  made  with  two  threads. .  The  threads 
are  carried  round  the  wound  at  a  distance  of  an  inch  or  less  from 
the  margin — one  under  the  muscular  coat,  the  other  under  the 
sub-mucous  tissue,  great  care  being  taken  that  nothing  enters 
the  mucous  membrane.  When  the  sutures  are  pulled  tight 
the  wound  is  gathered  together  in  a  rosette-like  form,  which 
alters  the  shape  of  the  bladder.  This  is  essentially  Tait's 
"flange  stitch,"  which  he  has  used  for  some  time  in  cases  of 
vesico-vaginal  fistula,  and  also  in  rents  of  the  hollow  viscera. 
Numerous  other  experiments  have  been  carried  out  with  the 
same  object  in  view.  The  majority  of  experimenters  combine 
in  recommending  interrupted  silk  sutures,  inserted  after  Lembert's 
plan,  or  some  simple  modification  thereof.  There  is  no  strong 
objection  to  the  use  of  catgut,  provided  it  be  chromicised ;  but, 
for  suture  of  a  peritoneal  wound,  silk  is  probably,  on  the  whole, 
the  best  material  to  use.     For  the  introduction  of  the  sutures  a 


OPERATIVE   TREATMENT.  733 

curved  or  corkscrew  needle  with  a  handle  is  best.  Keyes  of 
New  York,  in  an  operation,  used  a  Reverdin  needle,  and  speaks 
very  highly  of  it.  The  insertion  of  a  blunt  hook  in  the  top  of 
the  rent  may  add  to  the  facility  of  introducing  the  suture ;  and 
the  wound  may  further  be  steadied  by  first  inserting  two  or 
three  sutures  at  each  end  of  it,  and  handing  the  threads  over  to 
an  assistant,  who,  by  dragging  on  them,  keeps  the  wound  on  the 
stretch  and  towards  the  surface. 

MacCormac  very  wisely  continued  the  suture  for  some  way 
beyond  the  angles  of  the  wound,  thus  adding  to  the  length  of 
infolded  tissue,  and  strengthening  the  whole.  The  needle  used 
should  not  be  very  sharp-pointed.  Each  stitch  should  penetrate 
the  peritoneum  and  muscle,  but  no  stitch  should  enter  the 
bladder.  The  sutures  must  be  placed  closely;  about  eight  to 
the  inch   is  a  fair  proportion. 

When  the  sutures  are  tied,  and  the  wound  is  closed,  it  should 
at  once  have  its  security  tested  by  the  injection  of  warm  anti- 
septic fluid  into  the  bladder.  Should  it  be  found  water-tight, 
the  abdominal  cavity  may  now  be  irrigated,  and  the  wound 
closed.  Should  leakage  take  place  at  any  point,  additional 
sutures  should  be  inserted ;  for  this  purpose  Dupuytren's  con- 
tinuous suture  may  be  employed. 

Irrigation  of  the  whole  cavity  with  warm  antiseptic  fluid  is 
now  carried  out.  This  must  be  very  thorough,  and  must  include, 
not  only  the  pelvic  regions,  but  the  whole  cavity  as  high  as 
the  diaphragm.  Extravasated  urine  soon  becomes  diffused 
throughout  the  abdomen,  and  partial  cleansing  is  likely  to  be 
ineffectual.  If  the  fluid  is  of  a  temperature  exceeding  loo'", 
such  irrigation  is  further  beneficial  by  improving  the  condition 
of  shock. 

The  question  of  drainage  is  an  important  one.  Should  we  be 
fully  satisfied  as  to  the  trustworthiness  of  the  suture,  drainage 
need  not  be  employed  ;  but  it  will  sometimes  happen  that  the 
surgeon  will  not  be  satisfied  without  the  insertion  of  a  drainage 
tube.  The  tube  can  do  no  harm  ;  while,  by  permitting  the 
escape  of  any  fluid  that  may  leak  through  an  imperfect  stitch- 
hole,  it  may  be  of  conspicuous  benefit.     At  the  end  of  twenty- 


734  RUPTURE   OF  THE   GALL-BLADDER. 

four  hours,  should  it  appear  not  to  be  wanted,  the  tube  can 
easily  be  removed. 

It  is  usually  recommended  that  vesical  drainage  be  carried 
out  either  through  a  catheter  in  the  urethra,  or  through  an 
opening  made  in  the  perineum.  Perineal  section  adds  consid- 
erably to  the  risk  of  the  operation ;  and  the  retention  of  the 
catheter  has  been  found  to  be  unnecessary,  while  it  adds  to  the 
risk  of  urinary  decomposition. 

MacCormac  is  in  favour  of  leaving  the  bladder  to  empty 
itself.  He  says  that  if  the  rent  be  effectively  sutured,  the 
patient  runs  less  risk  from  moderate  distension  of  the  bladder, 
which  is  all  that  can  possibly  occur  in  a  case  properly  watched, 
than  he  does  from  the  practice  of  retaining  the  catheter  for  some 
days  within  the  viscus.  There  is  less  objection  to  drawing  the 
water  by  means  of  the  catheter  at  short  and  stated  intervals. 

The  making"  of  an  opening  in  the  bladder  behind  the  peri- 
toneum, as  in  supra-pubic  cystotomy,  has  been  recommended 
by  several  surgeons.  This  should  rarely  be  necessary;  and,  as 
it  adds  considerably  to  the  risk,  should  not  be  adopted. 


RUPTURE    OF    THE    GALL-BLADDER. 

Rupture  of  the  gall-bladder  will  rarely  be  diagnosed  as  a 
separate  lesion,  but  will  usually  be  come  upon  as  a  complication 
of  other  abdominal  lesions  for  which  operation  has  been  per- 
formed. Although  rupture  of  the  viscus  at  any  part  may  take 
place,  and  in  more  than  one  instance  the  whole  bladder  has 
been  found  completely  torn  away  from  its  attachment,  the  most 
common  seat  of  rupture  is  in  some  part  of  the  cystic  duct. 
Cases  of  rupture  of  the  common  duct,  and  of  the  hepatic  duct 
or  a  branch  of  it,  have  been  recorded." 

Experience  and  experiment  combine  to  show  that  the  escape 
of  bile  into  the  abdominal  cavity,  from  rupture  of  the  gall-bladder 
or  its  ducts,  is  not  necessarily  fatal.  Edler  gives  the  general 
mortality  at  74.2  per  cent.  This  mortality  would  certainly 
justify  operation  for  every  case,  if  the  operation  could  be  per- 
*  See  Morris,  Intcrnat.  Cyc.  Surg.,  vol.  v.,  p.  883. 


RUPTURE   OF  SOLID    VISCERA.  735 

formed  early.  In  most  cases  of  uncomplicated  rupture,  operation 
will  not  be  called  for  till  some  time  has  elapsed,  and  peritonitis 
has  developed.  In  every  case  where  the  diagnosis  is  probable, 
and  the  patient  is  in  a  fair  condition,  operation  should  be  per- 
formed. 

In  most  cases,  the  best  operation  would  probably  be  chole- 
cystectomy, or  removal  of  the  bladder.  Should  the  rent  be  a 
small  one,  and  within  convenient  distance,  it  ma}'  be  sutured. 
Should  it  lie  near  the  fundus,  it  may  be  sutured  to  the  margin 
of  the  parietal  wound,  as  in  cholecystotomy  for  gall-stones  or 
empyema.  Should  it  lie  deep  down,  or  involve  the  cystic  duct, 
a  ligature  should  be  placed  around  the  duct  below  the  seat  of 
rupture,  and  the  bladder  cut  away  above  it.  Rupture  of  the 
hepatic  or  common  ducts  are  beyond  the  range  of  surgical  inter- 
ference, except  by  drainage,  which  ma)'  keep  the  patient  alive ; 
while  protecting  or  uniting  adhesions  may  form,  and  restore 
the  continuity  of  the  canal.  The  formation  of  a  fistulous  com- 
munication between  the  common  duct  and  a  portion  of  intestine 
would,  if  it  were  practicable,  be  sound  surgery. 


RUPTURE    OF    THE    SOLID    VISCERA. 

Operation  in  rupture  of  the  solid  viscera  may  be  called  for 
either  on  account  of  haemorrhage,  or  the  formation  of  an  abscess 
in  the  wound,  or  suppurative  inflammation  in  the  peritoneum. 
The  primary  operation  to  check  haemorrhage  can  rarely  be  per- 
missible, on  account  of  the  usually  grave  nature  of  such  injuries, 
which  leaves  thepatient  in  a  condition  of  collapse  so  profound  that 
a  serious  surgical  operation  cannot  be  contemplated.  Second- 
ary bleeding  may  take  place  after  temporary  blocking  of  the 
vessel ;  then  operation  may  be  possible.  Success  is  most  likely 
to  follow  operation  when  the  patient  has  rallied  to  the  formation 
of  an  abscess  resulting  directly  from  the  traumatism,  or  to  the 
development  of  peritonitis  from  the  escape  of  the  gland  secretions. 
In  certain  cases  of  severe  injury,  removal  of  the  organ  may  be 
the  only  feasible  operation. 

Rupture  of  the  solid  viscera  is  produced  in  a  manner  very 


736  RUPTURE   OF  THE  SOLID    VISCERA. 

similar  to  rupture  of  the  hollow  viscera.  The  characters  of  the 
lesions  are  practically  the  same  as  in  penetrating  wounds :  their 
progress  is  similar,  and  the  symptoms  are  mostly  the  same. 
Therefore,  as  but  very  few  operations  have  been  performed  for 
this  class  of  injuries,  and  as  these  have  mostly  been  already 
described  under  the  organs,  a  special  description  need  not  here  be 
given.  Morton  has  collected  i8  cases  of  operation  for  rupture 
of  the  solid  viscera :  of  these  only  two  recovered.  For  further 
information,  the  reader  is  referred  to  Edler's  elaborate  mono- 
graph,* and  to  Morris's  article  on  "  Injuries  and  Diseases  of  the 
Abdomen,"  in  the  International  Cyclopc?dia  of  Siirgevy.\  With 
special  reference  to  rupture  of  the  liver  and  its  consequences,  as 
a  collection  either  of  pus  or  bile,  Briddon  I  writes  in  a  very 
suggestive  manner,  and  his  suggestions  are  supported  by  a  very 
successful  case.  Burckhardt,§  in  describing  his  case  of  suc- 
cessful operation  for  haemorrhage  from  a  wound  of  the  liver 
produced  by  a  stab  from  a  butcher's  knife,  deals  with  the  whole 
subject  in  a  very  instructive  manner. 

*  Arh.  f.  kliii  Chir.     1887.     xxxiv.        t  Vol.  v.,  p.  875. 
J  N.  Y.  Med.  Journ.,  Jan.  31st,  1885.  §  Centvalbl.  f.  Chir.     No.  5. 


OPERATIONS    FOR    SUPPURATIVE     PERITONITIS. 

In  this  sub-section  we  have  to  deal  with  those  conditions 
usually  grouped  under  the  name  of  suppurative  peritonitis.  In 
all  of  them  peritonitis  of  some  sort  exists  ;  but  in  some  of  them — 
as,  for  instance,  in  perforating  ulcer  of  the  stomach — the  inflam- 
mation may  not  have  had  time  to  proceed  to  positive  suppuration, 
although  this  ending  is  the  inevitable  one.  Operation  performed 
early  is  then  preventive. 

It  is  remarkable  how  many  cases  of  suppurative  peritonitis 
are  caused  by  perforative  ulceration  of  one  or  other  of  the  hollow 
viscera.  And  of  other  causes  of  suppurative  peritonitis,  certainly 
a  majority  must  be  attributed  to  direct  contamination  from 
escape  of  purulent  or  other  noxious  matter  from  contiguous 
collections.  Suppurative  peritonitis,  which  is  not  tubercular  or 
traumatic,  is  almost  invariably  connected  with  perforation  of 
viscera,  or  bursting  of  collections  of  pus  or  other  noxious  fluids. 

Cases  of  perforation  by  malignant  disease,  either  bi-mucous 
or  muco-peritoneal,  as  not  being  amenable  to  surgical  treatment, 
or,  at  least,  as  not  having  as  yet  been  so  treated,  are  not 
included. 


48 


Perforating  Appendicitis  ;   Caecitis  ;    Colitis. 

Much  uncertainty  exists  as  to  the  meaning  of  the  terms  usually 
employed  in  connection  with  the  inflammatory  diseases  of  the 
caecum.  Musser  "■''  attempts  to  give  definiteness  to  the  names  in 
general  use  by  using  typhlitis  for  inflammation  of  the  caecum  ; 
peri-typhlitis  for  inflammation  of  the  peritoneum  covering  the 
caecum  ;  and  para-typhlitis  for  inflammation  of  the  connective 
tissue  behind  the  caecum.  The  confusion  starts  with  the  name 
typhlitis:  it  has  no  definite  meaning.  Most  anatomists  maintain 
that  there  is  no  connective  tissue  behind  the  caecum ;  and  the 
term  para-tpyhlitis  would  by  them  be  rejected.  Inflammation 
of  the  caecum  can  scarcely  exist  without  inflammation  of  the 
peritoneum  which  covers  it,  and  therefore  the  term  peri-t3^phlitis 
is  superfluous. 

Pathological  knowledge  now  enables  us  to  give  names  that 
definitely  indicate  the  source  of  disease,  and  these  I  have 
ventured  to  adopt.  The  vermiform  appendix,  the  caecum,  and 
the  whole  length  of  the  large  bowel  are  liable,  at  any  part  where 
faeces  or  foreign  bodies  may  rest,  to  undergo  a  localised  inflam- 
mation which  has  a  tendency  to  ulcerate  and  permit  extra- 
vasation either  into  the  peritoneum  or  into  the  cellular  tissue 
overlying  the  wall  of  the  gut.  In  this  sense,  ischio-rectal  abscess 
is  identical  with  suppurating  peri-typhlitis.  The  clinical  results 
are  dependant  on  the  situation  where  the  perforation  takes  place; 
the  pathological  origin  is  essentially  the  same  for  all.  Naming 
according  to  locality  is  therefore  permissible,  and  we  may 
properly  speak  of  perforative  ulceration  of  the  appendix,  the 
caecum,  the  colon,  and  the  rectum. 

In  connection  with  abdominal  surgery,  it  happens  that 
perforative  appendicitis  is  by  far  the  most  important.  Caecitis 
that  perforates,  almost  of  necessity  involves  the  peritoneum;  but 
where  the  seat  of  inflammation  is  near  the  colon,  there  may  be 
cellular  infiltration  as  well.  In  the  transverse  colon  the  con- 
Med.  and  Surg.  Rep.,  Phila.,  Jan.  7th,   18S8. 


PATHOLOGICAL   ANATOMY.  739 

dition  is  rare ;  but  it  has  been  found,  and  has  been  described 
as  a  cause  of  bi-mucous  fistula  between  colon  and  stomach. 
In  the  descending  colon  it  is  more  common :  I  have  opened 
abscesses,  caused  by  perforatmg  colitis,  eight  times ;  and  I  have 
seen  two  other  cases  in  the  practice  of  colleagues. 


PATHOLOGICAL    ANATOJVTY. 

Inflammation  of  the  vermiform  appendix  is  usually  connected 
with  all  the  inflammatory  diseases  which  occur  in  the  right 
iliac  fossa :  in  other  words,  typhlitis,  in  the  vague  meaning 
which  it  usually  has,  is  said  to  depend  upon  this  cause. 

Fagge,  Wilks,  Fitz,  Musser,  Pepper,  and  indeed  most 
recent  writers  on  the  subject,  adopt  this  view.  Although 
there  can  be  no  doubt  that  the  majority  of  cases  of  so-called 
t\'phlitis  originate  in  this  way,  it  is  certain  that  a  few  do  not : 
at  least  one  such,  in  which  there  was  a  double  perforation  of  the 
caecum,  was  successfully  operated  upon  by  McMurtr}^  of  Dan- 
ville, Ky."''  Suppurative  appendicitis  is  a  perfectly  distinct 
disease,  having  no  more  relation  with  the  caecum  than  with  the 
ileum,  or  bladder,  or  an}-  other  contiguous  organ.  The  disease 
commences,  as  is  well-known,  in  a  catarrhal  inflammation  of  the 
mucous  m.embrane  of  the  appendix,  started  usually  either  by 
a  foreign  bod}'  or  by  faecal  concretions.  The  opening  of  the 
appendix  into  the  caecum  is  almost  uniformly  narrowed,  and 
pus  cannot  escape  backwards  into  the  caecum.  A  small  per- 
foration takes  place  in  the  appendix:  a  few  drops  of  putrid, 
perhaps  faecal,  matter  escape  into  the  peritoneum  and  set  up 
inflammation  of  that  membrane.  The  peritoneum  is  thickened 
in  the  neighbourhood  of  this  inflammation,  and  limits  the 
diffusion  of  the  pus.  As  suppuration  goes  on,  protective  inflam- 
mation takes  place  ahead  of  it,  and  successive  attempts  are 
made  to  prevent  general  diffusion  of  the  matter.  Should  one  of 
these  attempts  fail,  the  matter  escapes  into  the  peritoneal 
cavity,  and  we  get  what  ma}'  be  called  the  acute  termination  of 
perforative  appendicitis.  Should  the  attempts  at  conservative 
*  Journ.  Amcr.  Med.  Assn.,  July  7th,  188S. 
48   -^= 


740  PERFORATING  APPENDICITIS. 

limitation  of  the  matter  succeed,  we  get  an  abscess  surrounded 
by  a  mass  of  thickened  peritoneal  exudate,  which  may  remain 
imruptured  for  some  considerable  time.  This  is  a  chronic  term- 
ination of  the  disease.  Operative  treatment  is,  in  the  one  case, 
instituted  to  deal  with  diffused  peritonitis;  in  the  other,  with  a 
chronic  localised  abscess.  In  both  cases  the  mischief  lies  inside 
the  peritoneal  cavity.  It  is  scarcely  conceivable  that  it  should 
force  its  way  through  the  peritoneum  into  the  surrounding 
cellular  tissue. 

Pathological  descriptions  of  the  true  termination  of  this 
disease  are  usually  vague.  Some  would  seem  to  imply  that 
the  sub-peritoneal  cellular  tissue  has  been  entered,  and  that  the 
pus  has  burrowed  its  way  along  the  pelvic  fascia  or  in  other 
■directions ;  but  there  is  no  actual  proof  that  this  has  taken  place, 
and  in  the  face  of  the  abundantly  demonstrated  fact  that  the 
peritoneal  membrane  is  capable  of  almost  unlimited  powers  of 
thickening  and  condensation  in  the  neighbourhood  of  inflam- 
matory mischief,  we  should  want  very  cogent  proof  that  per- 
foration from  the  inside  actually  takes  place. 

In  the  case  of  early  perforation  with  diffuse  suppurative 
peritonitis,  there  may  be  a  very  small  abscess  sac  surrounding 
the  seat  of  perforation.  In  cases  of  a  chronic  nature  the  abscess 
may  be  of  considerable  dimensions  ;  more  than  a  pint  of  pus 
has  been  evacuated.  Of  course,  a  chronic  large  abscess  after  a 
prolonged  course  may  burst  into  the  general  cavity,  but  before 
this  takes  place  the  patient  is  brought  to  a  ver}'  low  ebb.  In  the 
centre  of  these  abscesses,  the  appendix  is  usually  found  in  a  state 
■of  acute  and  general  inflammation.  Occasionally  a  small  por- 
tion, or  even  a  considerable  part  of  it,  may  be  gangrenous. 

The  foreign  body  which  has  caused  the  perforation  may  or 
may  not  be  found  :  of  125  cases  collected  by  Dr.  Fenwick,  in  ^^ 
a  foreign  body  was  found  ;  probably  a  rigid  search  would  have 
discovered  one  in  a  greater  number.  Of  98  cases  of  perforation, 
13  were  caused  by  tubercular  and  6  by  typhoid  ulceration. 

In  the  case  of  acute  perforation  with  small  abscess  sac,  there 
is  no  surrounding  thickening  or  sign  of  inflammation  either  in  the 
abdominal  walls    or   in   the   contiguous    viscera.     Dulness   on 


SYMPTOMS.  741 

percussion  is  absent.  In  fact,  increased  resonance  may  be 
present.  In  a  chronic  case  with  a  large  abscess  there  is  cuta- 
neous oedema  in  the  right  lumbar  region,  with  general  thickening 
in  the  abdominal  cavity,  while  the  percussion  note  is  usually 
more  dull.  This  last  condition  is  very  similar  to  that  produced 
by  true  caecitis  or  typhlitis  or  peri-typhlitis,  as  the  condition  is 
impartially  named.  Here  also  we  may  have  thickening  of 
parietes,  with  oedema  or  even  redness.  The  inflammation  is  here 
caused  by  the  escaping  fluids  passing,  not  into  the  peritoneal 
cavity,  but  into  the  cellular  tissue  between  the  layers  of  the 
mesentery  of  the  colon.  The  induration  is  more  even,  it  is 
nearer  the  surface,  and,  from  the  fact  that  it  surrounds  the  colon 
or  the  caecum  like  a  cup,  and  is  not  usually  very  thick, 
resonance  may  be  given  out  on  percussion. 

On  the  left  side,  perforative  colitis  produces  conditions  very 
similar  to  caecitis. 

SYMPTOMS. 

Perforative  appendicitis  is  usually  found  in  boys  between 
lo  and  13  years  of  age,  although  it  occurs  at  other  periods  of 
Hfe. 

The  symptoms  of  perforation  of  the  appendix  vermiformis 
are  either  very  acute,  or  acute  supervening  on  chronic,  or  chronic 
throughout. 

In  the  most  acute  cases  there  are  either  no  premonitory 
symptoms  whatever,  or  these  are  very  vague  and  unimportant. 
The  patient  is  suddenly  seized  with  severe  pain  in  the  iliac 
region,  symptoms  of  collapse  rapidly  set  in,  and  death  takes 
place  in  a  few  hours.  Vomiting,  rapid  thoracic  respiration, 
abdominal  distension,  and  the  ordinary  symptoms  of  violent 
suppurative  inflammation  of  the  peritoneum  are  present. 

In  the  second  class  of  cases  the  patient  will  have  complained 
for  a  few  days,  or  perhaps  weeks,  of  vague  obscure  pains  in  the 
right  iliac  region  ;  he  may  have  continued  getting  about  or  even 
doing  his  work,  and  may  have  exhibited  few  symptoms  of  illness 
beyond  constipation  and  dyspepsia  or  other  intestinal  disturb- 
ances.   Diarrhoea  is  sometimes  found.    Some  patients  have  these 


742  PERFORATIVE  APPENDICITIS. 

symptoms  more  marked  ;  they  are  obliged  to  stay  in  bed,  appetite 
is  capricious,  there  is  a  Httle  evening  temperature,  occasionally 
a  rigor,  and  constipation  is  decidedly  troublesome.  Suddenl}' 
these  symptoms  are  changed  for  others  of  a  violent  and  grave 
character.  Rupture  of  the  peri-appendicular  abscess  has  now 
taken  place,  and  the  pus  is  diffused  into  the  peritoneum.  A 
few  such  cases  have  become  acute  after  an  examination  by 
medical  men. 

In  the  chronic  cases  the  symptoms,  at  first  not  serious,  very 
gradually  become  more  grave.  In  these  cases  histories  of 
repeated  previous  attacks  are  not  uncommon.  Usuall}'  there 
is  a  history  of  long-standing  intestinal  derangement,  with  loss  of 
appetite ;  occasional  attacks  of  acute  pain  referred  to  the  right 
iliac  region  ;  and  sometimes  vomiting.  With  exacerbations  and 
remissions  the  disease  progresses  fitfull}^  until  finally  the  patient 
has  to  take  to  bed.  Evening  temperatures  (roi''  to  103°)  of  a 
hectic  character,  occasionally  with  rigors,  now  appear,  and  the 
patient  exhibits  the  well-known  symptoms  of  abscess  formation. 

Locally,  there  is  a  distinct  swelling  or  increased  hardness  in 
the  region  of  the  caecum.  There  is  dulness  on  percussion.  The 
overlying  skin  may  be  cedematous,  but  is  rarely  red,  and  there 
is  great  tenderness  on  pressure. 

A  most  important  sign  may  be  got  by  examination  through 
the  rectum. 

As  the  appendix  lies  near  to  the  brim  of  the  pelvis,  we  may 
expect  to  find  any  considerable  collection  of  matter  in  its  neigh- 
bourhood within  the  reach  of  the  finger  introduced  through  the 
rectum.  To  completely  examine  the  pelvis  with  this  object, 
it  has  been  recommended  that  the  whole  hand  should,  if  neces- 
sary, be  introduced.  The  existence  of  fluctuation  may  sometimes 
be  made  out  in  this  way.  In  any  case  the  detection  of  an 
inflammatory  mass  of  thickening  in  the  region  of  the  appendix 
is,  coupled  with  the  rational  symptoms  of  appendicular  inflam- 
mation, a  most  important  diagnostic  sign. 

In  the  case  of  true  caecitis  or  colitis,  either  in  the  neighbour- 
hood of  the  caecum  or  on  the  left  side,  the  pus,  escaping  into  the 
sub -peritoneal    connective    tissue,    at    once    sets    up   a   diffuse 


OPERATIVE   TREATMENT.  743 

cellulitis  which,  in  the  majority  of  cases,  proceeds  rapidly  to 
suppuration.  In  some  cases  the  inflammation  produces  that 
hard  brawny  form  of  inflammation  which  we  are  so  familiar 
with  in  pelvic  cellulitis ;  the  inflammation  is  diffused  along  the 
parietes  under  the  peritoneum,  either  coming  up  towards  the 
front  or  burrowing  towards  the  back,  and  most  frequently 
tending  to  point  somewhere  above  the  middle  of  the  crest  of 
the  ilium.  There  is  no  large  localised  collection  of  matter,  it  is 
spread  over  a  large  area,  and  lies  much  nearer  to  the  surface 
than  in  true  appendicular  suppuration.  I  believe  that  suppu- 
rative pericolitis  on  the  right  or  the  left  side  is  more  common 
than  is  generally  supposed.  Of  eight  cases  on  which  I  have 
noAV  operated  six  were  on  the  right  side,  and  most  of  these  had 
been  diagnosed  as  perityphlitis.  In  no  case,  fortunately,  has 
it  been  possible  to  verify  the  diagnosis  post-mortem ;  but  a 
large  retro-peritoneal  abscess  in  the  lumbar  region,  with  con- 
tents of  a  foul  fffical  odour,  must  have  originated  in  a  perfora- 
tion of  the  colon  discharging  into  the  areolar  tissue  between 
the  layers  of  the  mesocolon. 


OPERATIVE    TREATMENT. 

Mild  cases  may  get  well  if  the  patient  is  kept  in  bed  at 
perfect  rest,  if  the  diet  is  such  that  no  residual  excrement  is  left, 
and  if  local  depletion  of  blood  or  counter-irritation  is  employed. 
But  it  must  be  remembered  that,  while  apparently  satisfactory 
progress  is  being  made,  acute  symptoms  may,  without  any 
warning  whatever,  come  on  to  indicate  that  perforation  has 
taken  place. 

A  good  many  such  cases  have  been  recorded,  and  in  some  of 
them  this  evil  result  has  apparently  been  due  to  manipulative 
interference  from  examination. 

When  to  operate  is  a  very  difficult  question  to  answer.     For 

recurrent  typhlitis  Treves*  has  had   the  courage  to  put  into 

practice   a   plan   which   at   once   commends   itself   to   favour; 

namely,  to  remove  the  appendix   after  the   acute   attack   has 

•  Med.-Chir.  Trans.,  vol.  Ixxi.,  p.  165,  and  Lancet,  Nov.  loth,  1S88. 


744  PERFORATIVE   APPENDICITIS. 

passed  off.  In  two  cases  on  which  he  operated  each  had  a 
diseased  and  distorted  appendix,  and  both  made  good  re- 
coveries. The  gravity  of  the  preceding  acute  attack  must 
be  the  criterion  as  to  the  propriety  of  operation  during  the 
period  of  calm  which  follows.  Fitz  in  his  valuable  monograph 
puts  down  the  hmit  at  three  days,  after  the  onset  of  acute 
symptoms,  striking  the  average  of  all  the  cases.  But  it  is  never 
safe  to  strike  an  average  between  extremes;  at  least,  to  act 
practically  upon  such  a  calculation  would  in  this  case  be  wrong. 
No  definite  rule  can  be  laid  down  as  to  the  time  of  operation. 
Symptoms  alone  must  guide  us.  It  is  true  that  perforation  in  a 
few  cases  takes  place  while  the  patient  is  in  apparently  good 
health.  These  cases  must  be  attacked  as  soon  as  possible  if 
serious  symptoms  come  on.  The  delay  of  even  a  few  hours 
may  make  all  the  difference  between  recovery  and  death  after 
operation.  In  sub-acute  cases  the  patient  should  be  put  to  bed 
at  once,  carefully  watched,  and  not  too  frequently  examined. 
Operation  should  be  performed  as  soon  as  the  patient  is  palp- 
ably drifting  into  a  condition  in  which  the  chances  of  recovery 
after  operation  are  markedly  diminishing.  Consecutive  evening 
temperatures  for  four  or  five  days,  rising  over  102°,  would  seem 
to  justify  operation.  Always,  on  the  supervention  of  acute 
s}^mptoms,  operation  should  at  once  be  performed.  In  the 
more  chronic  cases  delay  maj^  not  be  so  dangerous.  It  is 
rarely  possible  to  say  definitely  whether  the  chronicity  depends 
on  a  slight  degree  of  the  inflammation,  or  on  the  completeness 
with  which  the  suppurating  focus  is  shut  off  from  the  general 
cavity.  The  existence  of  a  mass  of  inflammatory  tissue  as 
detected  by  the  rectum  or  by  palpation  through  the  parietes  is 
an  indication  for  operation.  If  the  patient  is  losing  ground;  if 
hectic  supervenes,  possibly  with  rigors ;  and,  generally,  if  the 
condition  seems  to  be  drifting  into  one  in  which  operation  would 
be  dangerous  to  life,  then  we  should  interfere. 

In  the  case  of  peri -colic  suppurative  inflammation,  the 
decision  need  not  be  difficult :  operation  simply  waits  on  the 
formation  of  an  abscess  in  the  parietes,  as  it  does  on  the  forma- 
tion of  an  abscess  anywhere  else. 


OPERATIVE   TREATMENT.  745 

The  question  of  exploration  with  a  fine  aspirating  needle  has 
been  both  recommended  and  condemned.  If  the  suppuration 
is  deep  down  around  the  appendix,  the  use  even  of  a  fine  hypo- 
dermic needle  is  attended  with  danger  ;  an  aspirator  needle, 
under  any  circumstances,  need  not  be  used.  In  cases  of  doubt 
as  to  the  existence  of  pus  in  the  parietes,  there  is  no  objection 
to  the  use  of  a  needle  ;  but  to  push  the  needle  inside  the 
abdominal  cavit)',  and  through  several  layers  of  peritoneum, 
is  dangerous.  The  use  of  the  exploring  needle  by  the  rectum 
has  not  the  same  objection ;  but  here  also  its  use  is  not  free 
from  danger.  The  enlargement  of  the  exploratory  puncture  by 
the  rectum  into  an  opening  sufficient  for  drainage,  has  been 
recommended  and  carried  out ;  but  as  it  is  impossible  through 
this  route  to  make  out  the  actual  condition  at  fault,  or  to  remove 
the  diseased  or  gangrenous  appendix,  or  the  foreign  body,  we 
should  always  select  abdominal  section  when  the  patient  will 
bear  it. 

The  site  of  incision  should  be  selected  according  to  the 
ascertained  or  probable  position  of  the  actual  mischief  we  have 
to  deal  with.  In  most  cases  the  best  position  will  be  directly 
over,  or  a  little  to  the  inside  of,  the  position  of  the  caecum. 

Parker  made  an  oblique  incision  above  Poupart's  ligament. 
Some  surgeons  recommend  a  median  incision  ;  others,  one 
through  the  linea  semilunaris.  No  doubt  the  median  incision 
makes  it  certain  that  the  disease,  wherever  situated,  may  be 
reached  ;  but  if  the  abscess  is  small  and  lies  deep,  this  incision 
will  have  to  be  prolonged  to  a  considerable  length  to  expose  it. 

The  incision — vertical,  oblique,  or  transverse,  it  matters  not 
to  the  practical  surgeon  which — is  made  over  and  a  little  to  the 
inside  of  the  probable  seat  of  the  mischief.  It  is  carried  through 
the  peritoneum  in  the  ordinary  way.  Great  care  must  be  taken, 
at  every  step  of  the  manipulation,  that  bowel  is  not  injured,  and 
that  pus  is  not  diffused  through  the  peritoneal  cavity.  Should 
pus  appear  at  any  part  in  the  field  of  operation,  it  should  at 
once  be  mopped  up,  and  the  parts  infected  by  it  should  be 
cleansed  by  irrigation.  Cautiously  proceeding  downwards 
through   the   area   of  matting,   teasing   bowels   apart    between 


746  PERFORATIVE   APPENDICITIS. 

sponges,  never  using  the  knife,  isolating  the  healthy  portions 
from  the  diseased  with  sponges  or  sponge- cloths,  we  ultimately 
reach  the  seat  of  mischief.  Pus,  if  lying  free  in  the  cavity,  may 
be  sucked  out  by  a  syringe,  or  mopped  out  by  sponges,  or 
washed  out  by  the  irrigator.  At  the  bottom  of  the  cavity,- the 
diseased  appendix  will  usually  be  found.  It  should  always  be 
cut  away  :  this  is  simpler  and  safer  than  any  possible  method 
of  suturing  the  opening.  It  should  be  removed  close  to  the 
caecum.  It  may  be  cut  off  beyond  a  surroxmding  ligature,  and 
either  invaginated  bodily  inside  the  caecum,  which  is  stitched 
up  over  it ;  or,  after  being  tied,  the  serous  covering  may  be 
drawn  together  over  the  mucous  membrane  by  means  of  the 
figure-of-8  suture. 

The  parts  having  been  thoroughly  cleansed  by  washing  and 
by  sponging,  the  drainage-tube  is  inserted  and  carried  through 
the  opening  in  the  parietes.  Adhesions  between  bowels  are,  as 
far  as  possible,  left  undisturbed. 

The  advantage  of  having  the  incision  in  the  parietes  directly 
over  an  abscess-cavity  is  more  apparent  now  that  we  have  to 
institute  drainage. 

If  the  caecum  has  been  perforated,  the  opening  may  be  turned 
inwards,  and  the  serous  coat  drawn  together  by  a  Lembert's  or 
a  Dupuytren's  suture.  The  abscess -sac,  if  there  is  one,  is 
thoroughly  cleansed,  and  a  drainage  tube  placed  at  the  bottom 
of  it  and  carried  out  through  the  parietal  wound. 

If  there  is  diffuse  peritonitis,  the  whole  cavity  must  at  the 
same  time  be  thoroughly  cleansed  by  irrigation. 

Peri-colitis  resulting  in  abscess  is  practically  a  retro-peritoneal 
abscess,  and  its  treatment  requires  no  special  description.  On 
evacuation  of  the  abscess,  the  opening  in  the  bowel  sponta- 
neously heals  in  the  great  majority  of  cases. 


Perforating   Ulcer   of  the    Stomach. 

Pathological  Anatomy. — It  is  unnecessary  that  I  should  give  a 
detailed  account  of  the  pathological  anatomy  of  ulcer  of  the 
stomach.  The  following  points  are  noteworthy  from  a  surgical 
point  of  view.  The  disease  occurs  in  women  tv/ice  as  frequently 
as  in  men.  In  women,  perforation  is  most  liable  to  take  place 
between  the  ages  of  14  and  30;  in  men,  curiously  enough,  the 
average  age  at  which  perforation  occurs  is  42,  and  the  propor- 
tion of  cases  increases  up  to  50.  From  a  surgical  point  of 
view,  it  is  important  to  note  that  the  perforating  ulcer  lies,  in 
the  large  majority  of  cases,  in  the  anterior  wall  of  the  stomach. 
Dreschfeld  '•'  says  that  the  ulcer  perforates  on  the  anterior 
surface  85  times  out  of  100  cases  ;  while,  on  the  posterior 
surface  onl}'  2,  and  in  the  pylorus  only  10,  out  of  100  per- 
forate. 

It  is  a  pathological  fact,  confirmed  by  clinical  experience, 
that  those  ulcers  v/hich  perforate  are  usually  those  which  have 
given  but  slight  indications  of  their  presence.  Profuse  haema- 
temesis  occurs  in  those  cases  where  the  ulcer  lies  near  to  the 
large  vessels  close  to  the  curvatures,  and  here  perforation  does 
not  usually  take  place.  Severe  pain  is  usually  an  indication  of 
peritonitis  taking  place  over  the  ulcer,  and  this  peritonitis  is 
protective  against  perforation.  Dilatation  of  the  stomach  arises 
mostly  from  cases  where  the  ulcer  is  situated  near  the  pylorus; 
here  we  usually  find  enormous  hypertrophy  of  the  muscular  tissue, 
as  well  as  peritoneal  thickening,  and  here  also  perforation  is 
uncommon. 

Symptoms. — The  ordinary  symptoms  of  perforation  of  sto- 
machic ulcer  are — pain,  collapse,  t3-mpanitic  distension  of  the 
abdomen,  with  fixation  of  its  parietes,  thoracic  respiration,  and 
frequent  retching,  but  not  vomiting. 

The  pain  is  usually  very  severe,  and  comes  on  in  paroxysms 
*  Med  CJiroH.,  Nov.,   1887. 


748  PERFORATING    ULCER   OF  STOMACH. 

similar  to  those  observed  in  colic.  It  frequently  comes  on  after 
some  violent  exertion,  but  also  has  a  definite  relation  to  fulness 
of  the  stomach.  In  many  there  is  no  apparent  special  cause. 
Profound  collapse  is  present  at  the  outset  in  many  cases  ;  but  in 
some  the  collapse  is  only  nerve-shock,  induced  by  extreme 
pain.  As  the  collapse  increases,  and  becomes  profound  and 
constitutional,  the  pain  diminishes. 

Tympanitic  distension  may  come  on  very  soon,  with  hard 
tense  parietes.  Rigidity  of  parietes,  a  sort  of  reflex  spasm, 
affecting  the  abdominal  muscles,  and  preventing  abdominal 
movements  of  any  sort,  is  described  as  frequently  present.  This 
rigidity  has  been  found  to  accompany  a  depressed  abdomen, 
but  more  frequently  there  is  distension;  in  any  case,  distension 
soon  appears.  Tympanitic  resonance,  usually  most  marked  in 
the  epigastric  regions,  is  a  common  sign.  Associated  with  this 
condition  we  sometimes  find  the  very  important  sign  of  dis- 
appearance of  the  iiver-dulness.  This  sign  is  important,  because 
it  indicates  the  presence  of  free  gas  in  the  abdominal  cavity, 
and  can  scarcely  arise  from  any  other  cause  than  perforation 
of  an  air-containing  viscus,  such  as  the  stomach  or  the  intestine. 
The  value  of  this  sign  is  lessened  if  the  case  is  not  seen  very 
early  after  the  advent  of  the  acute  symptoms  ;  as,  later  in  the 
case,  it  is  liable  to  be  confused  with  general  intestinal  distension, 
or  special  distension  of  the  transverse  colon.  It  is  a  presump- 
tive sign  in  favour  of  the  presence  of  free  gas  in  the  cavity  if  it 
changes  its  position  with  that  of  the  patient,  always  rising  to  the 
highest  part  of  the  abdomen. 

Vomiting  is  nearly  always  absent  in  perforating  ulcer  of  the 
stomach,  though  there  is  usually  nausea,  with  retching  and 
eructations.  Vomiting  is  probably  a  mechanical  impossibility  ; 
the  compressed  stomach  discharges  its  contents  into  the  general 
cavity  through  the  perforation,  and  not  through  the  gullet. 

In  a  short  time  unequivocal  signs  of  peritonitis  appear.  The 
superficial,  quick  thoracic  respiration ;  the  fixed,  hard,  tense, 
and  perhaps  distended  parietes  ;  the  quick,  thready,  feeble  pulse, 
and  the  profound  general  disturbance,  clearly  indicate  the 
oncome  of  peritonitis  in  aggravated  form.     The  temperature  is 


OPERATIVE   TREATMENT.  749 

misleading ;  in  the  worst  cases  it  is  subnormal.  Then  we 
observe  the  pinched,  anxious  countenance,  the  diminution  or 
loss  of  pain,  and  the  advancing  collapse,  with  cold,  clammy 
skin,  which  indicate  the  approach  of  death. 

A  very  few  cases,  too  few  to  be  for  a  moment  considered  in 
drawing  up  rules  as  to  treatment,  have  recovered.  In  these 
cases  it  is  safe  to  infer  that  the  opening  was  small,  and  partly 
protected  b}'  exudations,  and  that  the  extravasation  was  limited 
in  amount. 


operative  Treatment. — As  to  the  advisability  of  operative 
treatment,  from  a  theoretical  point  of  view,  there  can  be  no 
dispute ;  operation  alone  will  put  the  patient  into  a  con- 
dition where  recovery  is  possible.  The  practical  drawbacks  are, 
the  condition  of  the  patient,  usually  so  grave  as  almost  to 
contra-indicate  operation,  and  the  frequent  uncertainty  as  to 
diagnosis.  It  has  been  suggested  that  all  cases  of  sudden  and 
severe  abdominal  shock  should  be  treated  by  operation ;  a 
hearty  agreement  with  this  suggestion  would,  however,  probably 
add  many  cases  of  aggravated  colic  to  the  already  large  list  of 
diseases  for  which  abdominal  section  has  been  performed.  In 
less  acute  cases,  where  the  patient  rallies  to  an  attack  of  peri- 
tonitis, operation  is  most  likely  to  be  successful,  provided  tJie 
patient  is  not  permitted  to  sink  too  low. 

The  operation  has  as  yet  scarcely  a  history.  Several  sur- 
geons have  strongly  advocated  it,  and  very  few  surgeons  can 
have  been  brought  into  contact  with  a  case  without  having 
the  operation  suggested  to  their  minds.  Of  the  few  operations 
performed,  not  more  than  one,  or  perhaps  two,  have  been  fol- 
lowed by  success.  Sinclair  of  Manchester  ••'  was  very  near 
having  a  success,  although  he  did  not  reach  the  perforation  ; 
the  patient  lived  six  days  after  operation.  Czern}-,  in  a 
case  which,  like  Sinclair's,  was  sub-acute,  and  operated  on  five 
days  after  perforation  had  taken  place,  found  odourless  gas  in 
the  cavity,  and  points  out  that  the  presence  of  gas,  with  a  faecal 
*  Med.  Chron.,  May,  1887. 


750  PERFORATING    ULCER   OF  STOMACH. 

odour,  would  indicate  perforation  of  the  large  intestine  or  the 
lower  ileum,  A  second  case,  more  acute,  died."  In  Sinclair's 
case  there  was  no  escape  of  gas  on  opening  the  peritoneum. 

From  the  reports  of  the  cases  published  so  far,  it  is  impossible 
to  draw  definite  conclusions  as  to  the  best  method  of  operating. 
The  proceeding  need  not  be  difficult,  but  it  should  be  conducted 
in  a  manner  so  as  to  give  the  most  perfect  results  in  the  shortest 
possible  time.  A  long  incision  will  usually  be  necessar3\  As 
soon  as  the  fact  of  perforation,  or  of  suppurative  peritonitis,  has 
been  demonstrated,  it  will  be  a  good  plan  at  once  to  commence 
irrigation  with  hot  aseptic  lotion.  The  value  of  irrigation  with 
hot  fluid  has  already  been  demonstrated  sufficiently  to  justify 
its  adoption  in  all  cases  of  abdominal  operations  where  shock 
and  extravasation  of  fluids  into  the  cavity  exist.  In  any  case, 
irrigation  will  have  to  be  carried  out,  and  it  may  as  well  be 
carried  out  during  the  exploration  for  the  seat  of  perforation, 
and  the  closure  of  it,  as  afterwards. 

As  to  the  technique  of  the  operation,  nothing  need  be  added 
to  the  description  of  gastrorraphy  already  given.  It  is  there 
recommended  that  the  edges  of  the  ulcer  should  be  pared. 
Experience  may  prove  this  to  be  unnecessary.  But  we  know  so 
little  of  the  true  pathology  of  gastric  ulcer,  that  we  cannot 
guarantee  a  cessation  of  the  disease  after  operation ;  there- 
fore, as  it  adds  little  to  the  difficulty  or  the  danger  of  the 
operation,  the  edges  of  the  perforation  had  better  be  cut 
awa}'. 

*  Beil.  ziim  Ccntralbl.  f.  Cliir.,  No.  24,  1888. 


Perforating  Typhoid  Ulcer. 

Kussmaul  of  Strasbourg,*  Bartleet  of  Birmingham  (unpub- 
lished), Morton  of  Philadelphia,!  Liicke,]:  Volkmann,  Mikulicz, 
and  Bontecou  of  New  York  §  have  performed  operations  for 
perforating  t3'phoid  ulcer.  Four  years  ago,  in  the  Bristol 
Infirmary,  I  opened  the  abdomen  for  a  large  collection  of  pus 
and  faecal  matter,  which  may  have  originated  in  this  way. 
There  was  a  double  perforation  through  the  large  bowel  as  well 
as  the  small ;  the  material  of  rectal  enemas,  as  well  as  partly 
digested  food  given  by  the  mouth,  came  out  through  the  parietal 
fistula  which  was  formed.  The  patient  lived  four  weeks,  and 
died  of  exhaustion.  As  no  post-mortem  examination  was  per- 
mitted, it  is  impossible  to  say  whether  the  disease  was  really 
typhoid  fever.  So  far,  only  one  case — that  of  Mikulicz — has 
recovered ;  and  it  was  doubtful  if  the  ulcer  was  t3'phoid. 
Dr.  James  C.  Wilson  ij  was  the  first  publici}'  to  recommend 
operation  for  these  cases.  Morton  has  operated  twice,  and  has 
carefully  worked  out "  the  conditions  for  which,  and  under 
which,  the  operation  may  be  performed. 

It  is  quite  impossible  to  lay  down  positively  the  principles 
which  should  guide  us  in  selecting  cases  suitable  for  operation. 
A  selection  of  cases  is  clearly  necessar}-.  To  perform  abdominal 
section  on  most  cases  of  perforating  typhoid  ulcer,  would  be 
little  better  than  performing  a  post-mortem  examination  on  the 
operating  table.  Perforation  frequentl}^  takes  place  during  con- 
valesence ;  a  few  of  these  cases  may  permit  of  operation. 
Most  cases  justifying  operation  will  be  of  the  very  mildest  or 
"ambulating"  variety.  The  operation  has  undoubtedly  a  future 
before  it ;  but  it  must  be  undertaken  onl}'  with  extreme  caution, 

*  Deutsche  Zeit  f.  Chiy.,  i8S6 — 7,  xxv.,  i.,  4. 

t  Med.  News,  Phila.,  Nov.  26th  and  Dec.  24th,  1887. 

I  Deutsche  Zeit.  f.  Chiy.,  xxv.,  i.  §  Jouyn.  Aiitcy.  Med.  Ass.,  Jan.  28th,  i888. 

II  Phila.  Med.  Times,  Dec.  nth,  1S86,  *1  Loc.  cit. 


752  PERFORATING   TYPHOID    ULCER. 

and  under  the  most  favourable  conditions  as  regards  the  patient's 
condition  and  surroundings. 

The  symptoms  need  not  be  described.  It  may  be  noted  that 
the  acute  symptoms  of  sudden  perforation,  with  abundant 
extravasation  of  visceral  contents,  are  by  no  means  always 
present.  In  a  few  the  symptoms  are  simply  those  of  peri- 
tonitis ;  and,  in  some,  the  symptoms  are  so  obscure  that 
perforation  is  not  even  suspected. 

As  to  the  operation  itself,  I  cannot  do  better  than  utilise 
Morton's  description  of  it : 

"  Median  incision  will  undoubtedly  prove  best  in  almost 
every  case.  It  should  be  as  long  as  is  necessary  for  efficient 
work,  and  commence  a  little  more  above  the  pubes  than  is 
usual  in  such  incisions.  Extreme  gentleness  will  be  required 
throughout,  as  otherwise,  perhaps  in  any  case,  other  ulcers  may 
be  broken  through.  Let  systematic  search  for  lesions  commence 
at  once  upon  gaining  admission  to  the  peritoneal  cavity,  starting, 
in  order,  at  the  points  most  liable  to  involvement.  We  should 
examine  the  caecum  and  its  appendage ;  then  carefully  go  over 
the  entire  length  of  the  small  intestine  continuously,  from  its 
termination  in  the  caecum  to  its  origin  at  the  pylorus,  by  passing 
it  between  the  fingers.  This  finished,  in  like  manner  the  colon 
should  be  examined  ;  then  the  mesentery,  ovaries,  liver,  etc. 

"  What  shall  be  done  with  lesions  when  found  ?     This  is  a 
vital,  and  not  an  altogether  answerable,  question. 

"  Perforations,  in  the  great  majority  of  cases,  will  be  found 
in  the  small  intestine  corresponding  to  the  position  of  Peyer's 
patches.  Occasionally  a  follicle  ulcer  will  perforate  near  the 
mesenteric  border,  but  probably  never  so  close  to  it  as  to 
produce  the  trying  injuries  which  are  made  by  a  bullet  or 
knife.  In  the  caecum,  or  colon,  perforation  is  equally  liable  to 
occur  anywhere,  except  close  to  the  meso-colon  attachments. 
The  usual  position  of  these  lesions  is  fortuitous,  as  the  situation 
permits  of  most  easy  reparative  treatment. 

"  Shall  we  resect  a  perforated  bowel,  simply  turn  in  the 
borders  of  the  perforation,  or  attempt  the  production  of  an 
artificial  anus  ? 


PERFORATING   TYPHOID    ULCER.  753 

"  In  the  lack  of  experience,  nothing  positive  can  yet  be  said 
upon  this  point.  We  do  know  that  circular  gangrene  of  intes- 
tine occurred  in  the  single  instance  where  exsection  has  been 
done ;  but  this  may  possibl}^  have  been  due  to  some  defect  of 
operation.  A  large  perforation,  or  a  small  opening  through  the 
base  of  a  very  large,  deeply  excavated  ulcer,  would  probably 
require  excision  of  a  portion  of  bowel.  Such  an  ulcer  occurring 
in  the  small  intestine  would  be  in  its  longitudinal  diameter  ; 
hence  it  can  be  turned  into  the  bowel  entire  by  Lembert 
sutures  introduced  beyond  its  lateral  borders.  This  I  should 
be  inclined  to  think  the  best  method  of  dealing  with  most 
perforations,  or  ulcers  about  to  perforate.  The  possibility  of 
narrowing  the  bowel  immoderately  must  be  kept  in  constant 
view ;  and  where  the  above  suggested  mode  of  repair  would 
undoubtedly  give  rise  to  it,  resection  or  artificial  anus  must  be 
substituted. 

"  It  is  possible  that  the  necrosis  of  bowel  already  alluded  to 
resulted  from  the  absence  of  resistance  in  tissues  so  profoundly 
poisoned  and  malnourished  as,  of  necessity,  are  those  of  a  typhoid 
individual.  We  do  not  even  know  what  course  the  parietal 
incision  itself  would  follow,  but  I  deem  it  probable  that,  with 
thorough  cleanliness,  such  wounds  could  be  induced  to  heal 
kindly.  At  the  worst,  happen  what  may,  the  patient  can  be  in 
no  more  deplorable  condition  than  before  operative  interference 
was  carried  out.  We  know  nothing  of  what  possibilities  there 
may  be  in  this  direction,  and  I  would  plead  for  an  attempt  to 
reduce  a  mortality  of  one  hundred  per  cent.  If  resection  cannot 
successfully  be  done,  and  the  affected  area  is  too  large  for 
efficient  stitching,  then  artificial  anus  would  be  another  resource. 

"Whether  any  one  of  these  three  methods  of  treatment  is  the 
one,  or  whether  all  will  have  occasional  use,  must  be  determined 
by  trial  and  experience.  The  order  in  which  I  should  suppose 
them  valuable  would  be :  stitching  by  Lembert's  method, 
resection,  and,  lastly,  artificial  anus. 

"  In  the  examination  of  the  intestine  I  should  also  be  inclined 
to  turn  into  the  bowel  lumen,  by  the  same  method  of  stitching, 
any  seats  of  disease  which  appeared  likely  soon  to  perforate,  or 

49 


754  PERFORATING   TYPHOID    ULCER. 

to  approach  dangerously  that  condition.  Caecum  and  colon 
lesions  could,  probably  in  every  case,  be  treated  by  simple 
stitching. 

"  Large  irrigations  with  ver}^  hot  distilled  or  medicated  water 
are  indispensable  before  closing  the  abdomen.  Just  as  important 
will  it  be  to  drain  these  cases  thoroughly,  and  for  this  purpose 
nothing  answers  so  well  as  the  leaving  in  of  a  Keith  glass-drain. 
This  tube  can  best  be  kept  in  working  order  ...  by 
carrymg  a  rope  of  absorbent  cotton  (medicated,  if  preferred) 
to  its  bottom,  and  removing  it  as  often  as  a  wad  of  cotton  placed 
over  the  outlet  becomes  saturated.  The  rope  and  superimposed 
cotton  must  be  renewed  as  it  becomes  saturated,  even  as  fre- 
quently perhaps  as  every  couple  of  hours  for  the  first  day; 
afterwards,  at  less  frequent  intervals,  according  to  circum- 
stances." 

Irrigation  with  a  hot  lotion  is  recommended  after  the  opera- 
tion on  the  bowel  is  concluded  ;  there  would  probably  be  no 
objection  to  irrigating  while  the  operation  is  going  on.  A 
drainage  tube  should  always  be  inserted. 


Perforative  peritonitis  may  be  induced  by  causes  other  than 
those  mentioned  above — as,  for  instance,  from  ulcer  of  the 
duodenum,  from  traumatic  ulceration  of  intestines  or  intestinal 
diverticula  produced  by  foreign  bodies,  and  from  progressive 
ulcerative  division  of  the  intestinal  coats  by  constricting  bands. 
In  the  urinary  bladder,  perforation  may  result  from  disease,  or 
from  ulceration  produced  by  calculus  or  foreign  body ;  in  the 
gall-bladder,  a  gall-stone  may  ulcerate  its  wa}^  through  its  walls, 
or  an  empyema  may  burst.  All  these  conditions  are  rare  ;  and 
as  operations  have  not  yet  been  performed  for  them,  they  need 
not  be  described. 

The  rupture  of  an  abscess  or  a  suppurating  cyst  may  be 
reckoned  among  the  causes  of  perforative  suppurative  peri- 
tonitis. 

Almost  any  abdominal  cyst  may  suppurate.  Strangulation 
from  twisting  of  the  pedicle  of  a  glandular  or  dermoid  cyst  of 


RUPTURE   OF  ABSCESS.  755 

the  ovary  may  cause  suppuration  of  its  contents,  and  these  may 
escape  into  the  abdominal  cavity.  A  glandular  pelvic  abscess  ; 
a  peri-typhlitic  abscess;  a  hepatic,  a  renal,  or  a  splenic  abscess, 
are  all  liable  to  burst  into  the  peritoneal  cavity.  Ovarian 
abscess  untreated  is  nearly  alwaj^s  fatal,  from  bursting  into  the 
peritoneum  :  and  pyo-salpinx  may  be  fatal  in  the  same  way. 
A  suppurating  extra -uterine  foetation  is  essentially  an  intra- 
peritoneal abscess,  and  death  is  frequently  caused  by  its 
rupture. 


49 


Purulent  Collections  in  the  Pelvis. 

To  give  an  adequate  account  of  the  whole  subject  of  pelvic 
inflammation  would  be  at  once  to  go  beyond  the  scope  of 
this  work,  and  to  trench  on  the  domain  of  pure  gynaecology. 
I  shall  therefore  do  little  more  than  name  the  conditions  found 
which  require  surgical  operation  ;  the  treatment  by  operation, 
being  simple  and  very  similar  in  detail  to  operations  just  re- 
viewed, will  be  described  very  briefly. 

The  great  majority  of  suppurative  inflammations  in  the 
pelvis  may  be  grouped  under  the  three  heads :  Pelvic  Peri- 
tonitis ;  Pelvic  Cellulitis  and  Abscess ;  and  Suppurating 
Hsematocele. 

Pelvic  Peritonitis,  which  ends  in  suppuration,  depends,  in  the 
great  majority  of  cases,  on  pyo-salpinx.  This  is  a  fact  not 
sufficiently  appreciated,  and  it  is  necessary  to  emphasise  it. 
Bernutz,  in  1857,  first  pointed  this  out,  and  much  pathological 
evidence  has  since  then  accumulated.  Bernutz  published 
reports  of  13  post-mortem  examinations  of  patients  dying 
with  pelvic  peritonitis  :  in  g  one  or  both  tubes  contained  pus, 
and  in  2  tubercular  products.  The  recent  investigations  of 
Polk,  Coe,  Noeggerath,  Foster,  Emmett,  and  many  others,  all 
point  in  the  same  direction.  Maury'''  has  collected  much  evi- 
dence in  support  of  this  fact,  and  considers  it  so  important  that 
he  prints  the  conclusion  to  be  drawn  from  his  evidence  in  Italic. 
He  considers  that  it  shows  "  that  the  common,  every-day  form 
of  chronic  pelvic  inflammation  which  attracts  the  attention  of 
the  gynaecologist,  as  well  as  the  simple  acute  pelvic  inflam- 
mation which  is  met  with  unconnected  with  septicaemia,  is 
pelvic  peritonitis  associated  with  diseased  appendages,  and 
is  not  pelvic  cellulitis." 

Pelvic  peritonitis,  not  suppurative  and  connected  with  the 
formation    of  adhesions    or   localised    collections   of  serum,  is 
*  Amer.  Syst.  of  Gynac,  and  Obstet.,  1887,  vol.  i. 


PELVIC  CELLULITIS.  757 

referred  to  in  the  section  dealing  with  removal  of  the  uterine 
appendages.  Here  we  have  to  deal  only  with  peritonitis  which 
results  in  suppuration.  The  walls  of  such  an  abscess  are  partly 
pelvic  viscera — uterus,  intestines,  rectum,  or  bladder — and  partly 
peritoneal  adhesions.  Somewhere  in  the  abscess-cavity,  being 
similarly  disposed  both  as  to  locality  and  as  to  cause  with  a 
perforated  vermiform  appendix,  lies  the  diseased  ovary  or  tube 
which  is  the  cause  of  the  mischief.  The  intestines  are  matted 
together  around  the  suppurating  focus,  and  their  function  may 
be  so  interfered  with  as  to  produce  s37mptoms  of  intestinal 
obstruction. 

Pelvic  Cellulitis  is  retro-peritoneal,  and  involves  the  whole  of 
the  para-metric  cellular  tissue  and  its  extensions;  that  is  to  say, 
it  may  involve  the  connective  tissue  which  surrounds  the  cervix 
and  upper  vagina,  passes  up  the  sides  of  the  uterus  between 
the  layers  of  the  broad  ligaments,  and  outwards  between  these 
structures  as  far  as  the  sides  of  the  pelvis,  and  even  beyond  this 
in  the  cellular  tissue  which  rises  over  the  peritoneum  under  the 
abdominal  parietes.  In  any  part  of  this  large  area  an  abscess 
may  form  either  as  a  direct  result  of  traumatism,  or  as  a  septic 
invasion  through  the  abundant  lymphatics.  In  this  category 
must  be  included  suppurating  pelvic  lymphatic  glands. 

The  abscess  may  burrow  in  almost  any  direction  in  the 
pelvic  cellular  tissue,  and  may  point  in  an  endless  variety  of 
situations  in  vagina,  rectum,  or  bladder,  and  through  the 
parietes  almost  anywhere  below  the  umbilicus.  The  purulent 
collection  is  always  sub-peritoneal,  and  rarely  bursts  into  the 
abdominal  cavity,  being  usually  fatal  through  high  temperature 
and  septic  absorption. 

Suppurating  Pelvic  HcBrnatocele  is  usually  extra-peritoneal,  and 
situated  between  the  layers  of  the  broad  ligament.  Intra- 
peritoneal ha^matocele  is  most  frequently  fatal  before  suppu- 
ration can  take  place ;  but  examples  of  degenerations  of 
sanguineous  fluids,  apparently  exuded  guttatim  from  an  un- 
health}'   tube   during   menstruation,   have   been   recorded.      A 


758  PURULENT  PELVIC  COLLECTIONS. 

suppurating  pelvic  haematocele  is,  when  fully  developed,  clini- 
cally and  anatomically  very  similar  to  pelvic  abscess  originating 
in  cellulitis. 

The  symptoms  of  a  collection  of  pus  in  the  pelvis  are 
sufficiently  definite,  and  do  not  require  detailed  description. 
The  constitutional  signs  of  suppuration  are  usually  well  marked ; 
the  temperature  is  usually  high,  sometimes  very  high.  The 
diagnosis  can  be  made  only  after  a  careful  digital  and,  if  neces- 
sary, bi-manual  examination  by  the  vagina  and  rectum.  It  is 
impossible  to  insist  too  strongly  on  the  importance  of  digital 
examination.  Percussion  through  the  parietes  may  be  mis- 
leading on  account  of  distension  of  the  intestines,  and  palpation 
from  the  front  may  reveal  nothing.  A  pelvic  abscess  may,  and 
frequently  does,  kill  a  patient  without  producing  a  single 
external  sign  to  the  examining  hand  or  eye  beyond  abdominal 
distension  and  fixation  of  the  parietes.  In  every  individual  with 
symptoms  of  suppuration  inside  the  abdominal  cavity,  whatever 
be  the  history  of  the  case  or  the  age  of  the  patient,  a  careful  and 
exhaustive  vaginal  or  rectal  examination  should  be  made. 

Such  an  examination  will  reveal  either  induration,  with  a 
localised  enlargement  somewhere  in  the  pelvis,  or  a  positive  col- 
lection of  fluid.  This  collection  may  occupy  Douglas's  pouch, 
and  bulge  into  the  vagina  behind,  displacing  the  uterus  forwards; 
or  it  may  lie  on  one  side  of  the  uterus,  pushing  this  organ  to  the 
opposite  side,  and  forcing  downwards  the  vagina  laterally;  or  it 
may  seem  to  occupy  the  whole  pelvic  cup,  pushing  down  its 
floors  and  surrounding  the  true  pelvic  organs.  In  other  cases 
there  is  only  induration  along  the  cellular  planes  in  the  pelvis, 
while  the  purulent  collection  lies  near  to  the  abdominal  surface, 
or  actually  in  the  abdominal  wall. 

The  diagnostic  examination  usually  causes  great  pain,  and 
may  have  to  be  conducted  under  an  anaesthetic  ;  in  every  case 
the  surgeon  should  be  prepared  to  operate  at  once  on  the 
diagnosis  being  made,  and  while  the  patient  is  still  anaesthetised. 


OPERATIVE   TREATMENT.  759 

Operative  Treatment. — The  indication  to  operate  in  suppurating 
pelvic  inflammations  is  as  clear  and  definite  as  the  indication  for 
any  other  abscess,  and  should  be  acted  upon  without  delay. 

As  to  the  mode  of  operation,  two  conditions  of  prime 
importance  must  be  taken  into  account:  one  is  the  condition  of 
the  patient ;  the  other,  the  point  at  which  the  abscess  may  most 
easily  be  reached  and  drained.  My  experience  is,  that  these 
patients,  when  the  surgeon  is  called  in,  are  very  ill,  with  exceed- 
ingly high  temperature  (io4°-io6'')  and  profound  constitutional 
disturbance.  In  some  of  them  there  will  be  symptoms  of 
intestinal  obstruction.  I  have  had  three  such  cases  in  my  own 
practice,  where  the  condition  I  was  called  in  to  treat  was 
described  as  intestinal  obstruction.  All  these  influences  com- 
bine to  add  to  the  risk  of  any  difficult  or  prolonged  operation. 
Again,  the  position  of  the  abscess  must  be  taken  into  account. 
An  abscess  lying  low  down  in  the  pelvis  cannot  be  drained 
through  the  anterior  parietes  without  carrying  the  pus  through 
a  health}^  district  of  peritoneum,  and  thereby  inducing  risk  of 
general  peritonitis.  Such  an  abscess  may  positively  invite 
opening  through  the  vagina.  And  this  invitation,  if  the  patient 
were  at  all  ill,  I  should  unhesitatingly  accept,  even  though  I  did 
not  at  that  operation  discover  and  remove  the  cause  of  the 
mischief.  Another  advantage  of  the  vaginal  opening  is,  that  it 
can  be  made  without  the  use  of  an  anaesthetize,  and  very  slightly 
upsets  the  patient. 

I  am  aware  that,  in  urging  these  views,  I  am  at  variance 
with  very  high  authority,  which  enjoins  a  uniform  opening  of 
pelvic  abscess  by  abdominal  incision.  I  would  urge  that  many 
of  these  cases  are  so  ill  that  the  administration  of  an  anaesthetic 
and  abdominal  section  are  proceedings  infinitely  more  grave 
than  a  simple  puncture  through  a  mucous  membrane ;  that 
drainage  by  vagina  can  efficiently  and  safely  be  carried  out  so 
as  to  cause  immediate  collapse  of  the  abscess  sac  ;  and  that  if  the 
issue  of  the  case  proves  that  the  origin  of  the  disease — a  suppu- 
rating ovary  or  tube — remains  and  requires  removal,  this  ma}'  be 
done  later  on,  when  the  patient  has  escaped  the  immediate  risk 
to  life  and  has  gained  strength. 


760  PURULENT  PELVIC   COLLECTIONS. 

In  one  such  case  I  found,  after  abdominal  incision,  that 
the  abscess-sac  lay  so  deeply  in  the  pelvis  that  its  walls  could 
not  have  been  brought  to  the  surface ;  I  therefore  opened  it 
into  the  vagina,  and  closed  the  parietal  wound.  In  another 
case — an  enormous  pelvic  abscess,  the  horribly  foetid  contents 
of  which  spouted  over  our  heads  through  the  long  exploring 
needle — I  was  unable  to  bring  the  walls  of  the  sac  to  the 
abdominal  opening,  and  the  drainage  tube  had  to  be  carried 
through  healthy  peritoneum.  In  a  case,  exactly  similar  to 
these,  about  five  pints  of  horribly  offensive  pus  were  evac- 
uated by  vaginal  incision ;  and  the  patient,  although  in 
the  last  stage  of  exhaustion,  made  an  excellent  recovery. 
Two  Infirmary  patients  treated  in  the  same  way  did  equally 
well,  and  one  of  these  would  almost  certainly  not  have  borne 
abdominal  section. 

While  I  advocate,  for  these  conditions,  the  application  of  the 
maxim  "  Ubi  pus,  ibi  evacua,"  I  would  not  seek  to  contest 
the  theoretical  advantage  of  operating  by  a  method  which  will 
enable  us  to  satisfactorily  deal  with  and  remove  the  cause  of 
the  disease.  Many  cases,  chiefly  those  in  which  the  abscess  is 
small,  can  be  dealt  with  only  by  abdominal  section  ;  and  others 
are  met  with  in  which  abdominal  section  is  quite  permissible, 
from  the  fair  condition  of  the  patient.  In  all  of  these,  the  direct 
incision  through  the  parietes  should  be  selected. 

A  detailed  account  of  the  operation  would  be  a  mere 
repetition  of  previous  descriptions.  The  wall  of  the  abscess  is 
usual!}'  more  or  less  completely  covered  by  adherent  intestine  : 
a  part  on  the  surface  is  looked  for  to  which  intestine  is  not 
attached,  and  here  the  aspirator  needle,  guarded  with  one  or 
more  sponges,  is  inserted.  As  the  sac  collapses  it  is  drawn 
towards  the  surface  by  means  of  catch-forceps,  and  if  possible 
attached  to  the  parietal  wound  by  a  continuous  suture.  In 
those  cases  where  the  sac  is  an  adventitious  one  composed  of  the 
walls  of  adherent  viscera,  this  is  impossible,  and  the  cavity  must 
be  drained  by  a  glass  tube  carried  to  its  bottom.  Here  the 
cavity  should  be  thoroughly  cleansed  b)'  irrigation  and  mop- 
ping with  sponges  charged  with  antiseptic  material.      Diseased 


TUBERCULAR   PERITONITIS.  761 

appendages,  if  discovered,  are  of  course  removed.  Adhesions 
between  intestines  need  not  be  broken  down  unless  it  is  neces- 
sary to  do  so  on  account  of  secondary  collections  of  pus.  The 
breaking  down  of  adhesions  seems  to  add  greatly  to  the  condition 
of  shock,  and  it  is  doubtful  whether  such  separation  of  adherent 
surfaces  is  more  than  temporary.  It  is  possible  to  do  too  much 
in  these  cases  ;  a  complete  and  perfect  surgical  technique  may 
be  carried  out  at  the  expense  of  the  patient's  life.  The  first 
essential  is  evacuation  of  pus  and  provision  for  drainage ;  then 
we  may  seek  to  isolate  the  cavit}'  of  the  abscess  by  suturing  its 
walls  to  the  parietal  opening ;  perfect  irrigation  and  cleansing, 
with  separation  of  adhesions  and  removal  of  causes,  is  the  final 
proceeding,  to  be  carried  out  only  if  the  condition  of  the  patient 
will  warrant  it. 


Tubercular   Peritonitis. 

The  operative  treatment  of  tubercular  peritonitis  has  been 
stumbled  on  by  accident,  rather  than  carried  out  by  design. 
A  good  many  cases  of  operation  for  encysted  cases  of  this 
disease  have  been  performed  by  mistake  for  ovarian  dropsy 
or  other  allied  condition.  Many  of  these  were  found  to  recover, 
and  hence  abdominal  section  for  tubercular  peritonitis  of  a  cer- 
tain class  has  come  to  be  carried  out  with  deliberate  purpose  as 
a  mode  of  treatment  promising  success.  Possibly  one  hundred 
such  operations  have  been  performed  in  the  last  twenty  j^ears. 

Dr.  Kuemmell  of  Hamburg*  collected  30  cases  of  this  kind, 
beginning  with  one  of  Spencer  Wells,  in  1862  Of  these  cases,  only 
2  died  directly  from  the  operation  ;  3  died  from  tuberculosis,  in 
periods  varying  from  5  to  12  months.  Altogether  there  were  25 
cures,  of  from  9  months  to  25  years'  duration.  No  doubt  many 
cases  died  which  were  not  reported,  and  it  is  probable  that  this 
mortality  is  too  favourable  ;  still,  there  can  be  no  doubt  that  a 
considerable  number  of  cases  of  undoubted  tubercular  peritonitis 
have  been  cured  or  have  had  their  lives  prolonged  b}'  abdominal 

section. 

*  Centralbl.  {.  Chir.,   1887,  xxv. 


762  TUBERCULAR   PERITONITIS. 

It  must  be  admitted  that  this  is  an  exceedingly  surprising 
fact.  Some  years  ago  I  operated  on  a  case  of  encysted 
ascites,  caused  by  tuberculosis  of  the  peritoneimi.  The  cavity 
was  washed  out  and  drained,  and,  speaking  from  the  information 
which  was  then  before  the  medical  profession,  I  had  no  hesitation 
in  prognosing  that  the  patient  would  die.  Death  took  place  at 
the  end  of  six  months,  and  diffuse  tubercular  disease  was  found 
affecting  the  peritoneum.  Alongside  of  this  case  I  may  quote 
one  recently  reported  by  Ely  van  de  Warker  of  New  York,'' 
which  is  similar  to  it  in  many  respects.  He  says:  "  I  made  an 
incision  about  five  inches  long,  fully  expecting  to  come  upon  a 
cyst ;  but  on  reaching  the  peritoneum,  no  separation  could  be 
made  between  it  and  what  ought  to  correspond  with  a  cyst-wall, 
and  yet  what  we  regard  as  the  peritoneum  was  enormously 
thick.  I  carefully  worked  my  way  through  it,  and  was  rewarded 
by  a  jet  of  fluid  from  what  appeared  to  be  a  cyst-cavity.  The 
incision  was  enlarged  to  the  full  extent  of  the  external  wound, 
the  patient  turned  upon  her  side  and  the  cavity  emptied.  Some 
further  attempts  were  made  to  separate  a  cyst-wall  from  the 
peritoneum,  but  it  only  resulted  in  tearing  the  peritoneum  from 
the  abdominal  wall.  The  idea  of  a  cyst  was  abandoned,  and 
we  confined  our  efforts  to  find  out  the  nature  of  the  case.  By 
inserting  the  hand  a  mass  was  brought  into  view  which  was 
so  thickened  and  matted  together  that  it  was  with  difficulty 
recognised  as  intestine.  The  peritoneum  was  rolled  out  and 
found  to  be  studded  with  a  great  number  of  tubercles,  from  the 
size  of  a  millet-seed  to  that  of  a  buck-shot — some  of  them  white, 
others  yellow.  The  intestines  were  everywhere  beset  with 
them.  The  transverse  colon,  thickened  and  covered  with 
tubercles,  was  adherent  to  the  peritoneum  from  side  to  side, 
thus  enclosing  the  cavity  and  giving  to  the  fluid  the  appearance 
of  being  confined  within  the  walls  of  a  cyst."  The  patient  made 
an  excellent  recovery  ;  and  at  the  end  of  three  months,  from 
being  in  a  condition  of  somewhat  marked  invalidism,  she  became 
a  strong,  robust  woman.  In  a  case  on  which  I  operated  in  the 
Bristol  Infirmary  in  April  of  this  year  which  had  a  solid  mass  of 
*  Jouvn.  Amer.  Med.  Assoc,  Nov.  5th,  1887. 


TUBERCULAR   PERITONITIS.  763 

caseated  material  in  one  broad  ligament,  and  the  whole  perito- 
neum covered  with  tubercles,  but  no  ascitic  fluid  and  no  adhesions, 
I  did  nothing,  being  convinced  that  meddlesome  interference 
would  only  accelerate  the  end. 

Similar  and  even  more  striking  cases  of  recovery  have  been 
recorded ;  and  altogether  there  can  be  no  doubt  that  the  operative 
treatment  of  tubercular  peritonitis  has,  in  many  cases,  been 
attended  with  extraordinary  success. 

It  may  be,  and  has  been  said  in  criticism  of  these  results, 
that  the  disease  in  these  cases  was  probably  not  tubercular  at 
all ;  but  more  than  one  case  has  shown  that  not  only  the  true 
structure  of  miliary  tubercle,  but  the  tubercle  bacillus  itself 
was  present.  In  four  cases  on  which  I  have  operated,  two  are 
as  yet  too  recent  (six  months  and  four  months)  to  draw  con- 
clusions from  ;  of  the  other  two,  one  died  after  six  months  wdth 
extensive  tubercular  disease  in  the  abdomen,  and  the  other  is 
steadily  losing  ground.  In  several  of  the  cases,  however,  in 
which  recover}^  has  foUow^ed  operation,  true  tubercular  tissue 
has  not  been  found.  It  is  just  possible  that  in  some  of  these 
cases  the  so-called  miliary  tubercles  were  simply  nodules  of 
inflammatory  lymph,  such  as  are  sometimes  found  on  inflamed 
pericardial  or  pleural  surfaces. 

Admitting  that  cases  of  undoubted  tubercular  disease  recover, 
several  surgeons  and  pathologists  have  attempted  to  give 
explanations  which  need  not  here  be  recapitulated.  No  expla- 
nation is,  in  my  opinion,  satisfactory  unless  we  review  the  whole 
of  our  knowledge  of  this  disease. 

It  is  more  than  probable  that  a  good  many  of  these  cases 
reported  as  cured  are  simply  quiescent,  like  caseated  lymphatic 
glands,  and,  as  time  passes,  may  develop  into  an  acute  con- 
dition and  kill  the  patient.  With  some  reservation,  the  evidence 
at  present  before  us  would  seem  to  suggest  that  those  cases  that 
get  well  are  examples  of  local  tuberculosis  isolated  by  peritoneal 
adhesions  and  bathed  in  ascitic  fluid ;  those  that  die  are  ex- 
amples of  general  diffusion  of  tubercle  without  adhesions  and 
not  encysted. 

As  to  the  diagnosis,  very  little  need  be  said  in  addition  to 


764  SUPPURATIVE   PERITONITIS. 

what  has  already  been  said  in  the  opening  sections.  The 
diagnosis  is  essentially  that  of  encysted  ascites.  In  a  few  cases 
there  may  be  pyrexia,  but  in  many  the  temperature  will  pursue 
a  normal  course.  Cases  of  diffuse  tuberculosis  invading  the 
whole  of  the  peritoneum  have  not  as  yet  come  within  the  domain 
of  operation,  and  nothing  need  be  said  of  their  diagnosis. 

The  operation  requires  no  special  description,  being  usually 
performed  on  an  uncertain  diagnosis  or  for  exploratory  purposes. 

The  first  steps  after  the  opening  of  the  peritoneum  should  be 
taken  with  extreme  caution.  The  adherent  bowels  or  omentum 
which  enclose  the  ascitic  fluid  in  front  are  carefully  separated 
and  the  cavity  exposed.  The  fluid  is  removed  either  by  the  use 
of  a  siphon  tube  or  by  sponging.  It  is  apparently  not  necessary 
on  even  expedient  to  use  a  strong  antiseptic  for  the  cavit)'. 
Irrigation  with  simple  hot  water  has  been  found  to  be  quite 
efficient.  The  drainage  tube  is  inserted,  the  wound  is  closed 
around  it,  and  the  dressing  and  after-treatment  managed  in  the 
ordinary  manner. 

Before  dismissing  the  subject  of  suppurative  peritonitis,  I 
desire  to  throw  out  a  suggestion  which  I  am  inclined  to  believe 
will  develop  into  a  useful  mode  of  practice.  It  is  that  cases  of 
suppurative  inflammation  of  the  peritoneum  should  be  treated 
with  a  wet  and  not  a  dry  peritoneum  ;  that  the  intestines  should 
be  kept  floating  for  a  few  days  in  hot  aseptic  or  antiseptic 
lotion.  Perfect  drainage  of  the  abdominal  cavity  becomes 
impossible  as  soon  as  a  few  coils  of  intestine  become  adherent. 
Intestinal  paralysis,  distension  and  vomiting  are  caused  by 
the  formation  of  peritoneal  adhesions ;  and  the  future  risk  to 
life  is  greatly  increased  where  peritoneal  bands  are  formed. 
I  believe  that  these  grave  conditions  are  best  met  by  keeping 
the  intestines  bathed  in  an  innocuous  or  mildly  antiseptic  fluid ; 
and  in  the  past  few  years  I  have  been  cautiously  acting  on  this 
belief.  The  results  so  far  have  been  very  encouraging  ;  and  I 
think  the  plan  merits  a  trial. 

The  fluid  which  I  use  is  hot  boro-glyceride  solution,  of  the 
strength  of  about  an  ounce  of  the  material  to  a  pint  of  hot 


SUPPURATIVE  PERITONITIS.  765 

water.  Boro-glyceride  seems,  in  addition  to  its  antiseptic  pro- 
perties, to  retain  some  of  the  hygroscopic  properties  of  glycerine; 
and  is  beneficial  to  the  engorged  and  inflamed  peritoneal 
membrane  in  a  similar  manner  to  glycerine  when  applied,  in 
vaginal  tampons,  to  the  uterus.  Through  the  drainage  tube  a 
quantity  of  the  solution  is  slowly  forced  into  the  cavity  by 
syringe  or  irrigating  resorvoir,  and  permitted  to  remain  in  the 
cavity,  or  even  compelled  to  do  so  by  temporarily  plugging  the 
orifice  of  the  tube.  The  fluid  should  be  hot — at  least  102°  Fah. ; 
I  have  always  noted  that  the  patient  derives  comfort  from  the 
injection  of  the  hot  fluid.  This  injection  may  be  repeated 
several  times  a  day. 


BIBLIOGRAPHY. 


DIAGNOSIS    OF   ABDOMINAL   TUMOURS. 

Ballard. — Phys.  Diag.  of  Dis.  of  Abdomen.     Lond.     1852. 

Bernutz.- — Art.    Abdomen.    Semeiologie.     N.  Did.  de   Med.  et  Chir.    Prat. 

Paris.     1864. 
Bright. — Clin.  Mem.  on  Abd.  Tumours.     New  Syd.  Soc.     i860. 
BuDiN. — Du  palper  abdominal.     Bull.  gen.  de  therap.     Paris,     xcvi.     1879. 
Corrigan. — "Leather-creak."     Dub.  Med.  Journ.     1836. 
CouiLLAULT. — De  III  symptomatologie     .     .     .     de  Vabdomen.     Paris.     1855. 
Delaigne, — Percussion  an  diagnostic  des  Maladies  de  l' Abdomen.     Paris.     1844. 
DuPUY. — Du  palper  abdominal,  &c.     Gaz.  Obstet.     Paris,     vii.     1878. 
Edis.- — Diag.  of  Abd.  Turn.     Cases.     Lond.  Obstet.  Journ.     vi.     1878. 
Forbes. — Exploration  of  Abdomen.     Cycl.  Pract.  Med.     Phila.     1845. 
GuTTMAN. — Physical  Diagnosis.     New  Syd.  Soc. 
Habershon. — Dis.  of  Abdomen.     London.     1878. 
Hart. — Atlas  of  Female  Pelvic  Anatomy.     Edinburgh. 
Hegar. — Zur  gynak.  Diagnostik.     Samml.  Klin.  Vortr.     1876.     No.  105. 
Hooker.- — Intestinal  Auscultation.     Boston  Med.  and  Surg.  Journ.     xl.     1849. 
Jenner. — Diagnosis  of  Extra-pelvic  Tumours.     Brit.  Med.  Journ.     1869,  i., 

and  1870,  i. 
Leale. — Intra-abdominal  Exploration.     N.  Y.  Acad.  Med.  Trans.     1874. 
LooMis. — Lectures  on  Physical  Exploration  of  Abdomen.     A^.  Y.  Med.  Rcc. 

1867.     ii. 
Pepper. — Fat   in   omentum,   &c.,   causing   error   in    Diagnosis.      Ayn.  Journ. 

Obstet.     ii.     1870. 
Piorry. — Diag.  difl:'.  des  tumeurs  de  I'abdomen.     Gaz.  d.  hop.     Paris.     1851. 
Reeve. — Diag.  of  Abd.  and  Pelvic  Tumours.     Amer.  Pract.     Louisville,     ix. 

1874. 
Sabatier. — Des  applications  de  la  percussion,  &c.     Pans.     1843. 
Schramm. — Diaphanoscope.     Jahresb.  d.  Gesellsch,  &c.     Dresden.     1876. 
SiEBERT. — Diag.  der  Kranhheiten  des  Unterliebes.     Erlangen.     1855. 
Simon. — Rectal  Palpation,  &c.     Deutsche  Klinik.     xxiv.     1872. 
Sommerbrodt. — Zur  Auscultation  des  Abdomen.    Bcrl.  Klin.  Woch.    x.     1873. 
Williams. — Physical  Exam,  of  Abd.     London  Journ.  Med.     1851-2. 
WiLLKAMP. — Rectal  Exploration.     Case.     Cincin.  Med.  News.     iii.     1874. 
WiNCKEL. — Ueber   Auscultation   des  Unterliebes.     Jahresb.  d.  Gesellsch,  &c. 

Dresden.     1874. 

PHANTOM    TUMOURS. 

Broca. — Monit.  d.  hop.     Par.,  i.,  1853,  P-  601. 

Da  Costa. — Philadelphia  Med.  Times,     i.,  1871,  p.  449. 

Greenhow. — Lancet,     i.,  1857,  P-  S^- 

Habershon. — Med.  T.  and  Gazette,     ii.,  1858,  p.  441. 

Paget. — Lancet,     ii.,  1873,  p.  833. 

Ramskill. — Med.  T.  and  Gazette,     xix.,  1859,  pp.  298,  579. 

Thomas. — Phila.  Med.  and  Surg.  Reporter,     xxx.,  1874,  p.  477. 

Wells. — Med.  Times  and  Gaz.     ii.,  1859,  p.  580,  and  i.,  1878,  p.  671. 


BIBLIOGRAPHY.  767 


ABDOMINAL   OPERATIONS    IN    GENERAL. 

Bantock,— 100  Consec.  Cases  of  Abdom.    Sect.     Lancet.     March   12th  and 

19th,  1887. 
BiGELOW. — A  Morning  with  August  Martin.     Amer.  J.  Obstet.     1886.     xix., 

p.  468. 
Discussion  on  Indications  for  Drainage.   Am.  Journ.  Obstet.    1886.   xix.,  p.  611. 
DoRAN. — Handbook  of  Gynaecological  Operations.     Lond.     1887. 
Emmet. — Germ,  and  Eng.  Gynaecology.   N  .Y.Med. Joiivn.    1886.   And  Reprint. 
Fowler. — Explorative  Laparotomy.     New  York.     1886. 
GooDELL. — A  Year's  Work  in  Laparotomy.     Phila.     1886. 
Hunter. — 50  Cases  of  Abd.  Sect.     N .  Y .  Med.  Journ.     1886.     And  Reprint. 
Persistent  pain  after  Abd.  Sect.     Trans.  Amer.  Gynac.  Assoc.     1886. 

P-  378. 
Mural  Abscess  following  Laparotomy.     Tr.  Amer.  Gyn.  Sac.     1886. 

X.,  317- 
Kelly. — Gynaec.  Operns.  in  Germany.    Phila.  Med.  Neivs.    1886.    xlix.,  p  301. 
McKiNNON. — Some  details  in  Ovariotomy.     Canada  Pract.     xi.,  p.  229. 
Mears. — Surgery  of  the  Abdomen.     Phila.     188S. 
Malcolm. — Intestine   after  Operation.      Tr.  Mcd.-Chir.  Soc.      Lond.      18S8. 

P.  43- 
Muller. — Zur   Nachbehandlung  schwerer   Laparatomien.     Cent.  f.   Gynlik. 

1886.     x.,  409. 
Munde. — Laparotomy  in  Europe.     Amer.  Journ.  Obstet.     1886.     xix.,  p.  897. 
Perkins. — 338  Operations  by  Dr    W.  Burnham.     Ann.  of  Gynac.     Boston. 

1887-8.     i.,  p.  339. 
Reed. — After-treatment.     Cincin.  Lane,  and  Clinic.     1886.     xvii.,  p.  329. 
Senn. — Present  Status  of  Abd.   Surgery.     Journ.  Am.  Med.  Ass.     1886.     vi., 

p.  617. 
Tait. — 1000  Cases  of  Abd.  Sect.     Brit.  Med.  Journ.     1885.     -A-^d  Reprint. 
Wylie  (W.  G.) — Obs.  on  Abd.   Surg.,  &c.     Trans.  Amer.  Gyncsc.  Soc.     1886. 

P.  503. 
Wyman. — Abdominal   Surgery,  and   how  to  learn   it.     Med.  Age.     Detroit. 

August  3rd  and  loth,  1887.     And  Physicians'  Leisure  Library. 

parotitis  following  abdominal  operations 

Berth. — Greifswald.     1886. 

Bougarel. — France  med.     1886.     ii.,  1232. 

Bumm. — Centralbl.f.  Gyndk.     1887.     xl. 

GooDELL. — Trans.  Am.  Gyn.  Soc.     1886.     x.,  211. 

Jalland. — Lancet.     1886.     ii.,  p.  916. 

Keith. — Ed.  Med.  Journ.     1886.     xxxii.,  p.  306. 

Stephen  Paget. — Lancet.     Jan.  9th,  1886. 

VoN  Preuschen. — Deutsche  Med.  Woch.     1886.     No.  51. 


OVARIOTOMY. 

special  works. 

Atlee. — Diagnosis  of  Ovarian  Tumours.     Phila.     1873. 

Baker-Brown. — On  Ovarian  Dropsy.     Lond.     1862. 

Clay. — Cases  of  Perit.  Sect,  for  Extirp.  of  Diseased  Ovaries.     London.     1842. 

DoRAN. — Tumours  of  the  Ovary,  &c.     London.     1884. 

Gallard. — Pathologic  des  ovaries.     Paris.     1886. 

GooDELL. — Dis.  of  Ovaries  and  Oviducts.    Pepper's.  Syst.  Pract.  Med.    1886.    iv. 

KoEBERLii. — Sur  le  traitement  des  Kystes  le  I'ovaire,  Sec.     Paris.     1865. 

LiZARS. — Observations  on  the  Extraction  of ■  Diseased  Ovaria.     Lond      1825. 

Peaslee. — Ovarian  Tumours.     New  York.     1872. 


768  BIBLIOGRAPHY. 

Tait. — Dis.  of  Ovaries.     Birmingham.     1883. 

Wells. — Ovarian  and  Uterine  Tumours,  &c.     Lond.     1882. 

Battey. — Antisepsis:  30  successful  cases.     Trans.  Med.  Ass.     Georgia.     18S4. 

P.  151. 
DORAN. — Papilloma  of  Fall.  Tube,  &c.     Brit.  Med.  Journ.     1886.     ii.,  p.  722. 
Elliot. — Suppurating  Tumours  :  Drainage.     3  Cases.     Boston  Med.  and  Surg. 

Journ.     1886.     cxv.,  p.  441. 
GooDELL. — Intraligamentary  Ovarian  Cysts.    Amer.  Journ.  Obstet.    Jan.,  1888. 
GuiCHARD. — Dermoid  Cysts.     Bull.  Soc.  Obstet.,  &c.     Par.,  1886.     i.,  p.  171. 
Helmuth. — 33  Laparotomies.     Am.  Journ.  Obst.     1886.     xix.,  p.  1136. 
Herman. — Suppuration,  &c.,  of  Dermoid   Cysts.     Trans.  Obstet.  Soc.     1886. 

xxvii.,  p.  254. 
Hooks — -Ovariotomy,  dermoid  :  Child  of  30  months.    Am.  Journ.  Obst.    1886. 

xix.,  p.  1022. 
Keith  (Skene). — Cases.     Edin,  Med.  Journ.     1886.     xxxi.,  p.  837. 
KoEBERLE. — Treatment   of  Pedicle,    &c.      Mem.    Soc.   de  Med.      Strasbourg. 

1884-5.     xxii.,  p.  80. 
Le  Bec. — Ovariotomy.    Death  from  Volvulus.    Gaz.deslwp.    1886.    lix.,  p.  687. 
Lee. — Internal.  Ency.  Surg.     1886.     vi. 

Macan. — 14  Cases.     Trans.  Acad.  Med.,  Ireland.     1885.     iii.,  p.  210. 
MuNDE. — Ovariotomy  during  Peritonitis.     Med.  and  Surg.  Rep.     Phila.     1886. 

Iv.,  300,  328. 
MuNK. — Ein  Beitrag  zu  den  Dcrmoidcysten  des  Ovarium.     Tiibingen.     1885. 
Olshausen. — Statistik  der  Ovariotomie.     Deutsche  Chirurgie.     Lf.  58. 
Parizot. — De  la  torsion  du  pedicule,  &c.     Paris.     1886. 
Perruzzl — 500    Ovariotomies    in    Italy.      Abst.    in   Amer.    Journ.   Med.    Sc. 

April,   1885. 
Polaillon. — Sarcoma.     Operation.     Bull.  Soc.  Obst.     1886.     i.,  p.  52. 
Skene. — Dis.  of  Ovaries  and  Oviducts.     Pepper's  Syst.  Pract.  Med.     1886.     iv. 
Tait. — 139  Consec.  Succ.  Ovariotomies.     Brit.  Med.  Journ.     1886.     i.,  p.  921. 
Terrillon. — Faux  Kystes  de  I'ovaire.     Ann.  de  gynec.     1886.     xxvi.,  p.  245. 

Kystes  parovairiques,  &c.     Paris.     1886. 
Thiria. — 25   Successful    Ovariotomies.      Journ.  de  Med.,   Sec.      Brux.      1886. 

Ixxxiii.,  p.  485. 
Thornton. — 300  Ovariotomies.     Lancet.     1886.     ii.,  p.  818. 


REMOVAL  OF  THE  UTERINE  APPENDAGES. 

inflammation  and  abscess  of  the  ovaries. 

Alexander. — On  Removal  of  the  Ut.  App.  for  Infl.  Disease.     Med.  Press  and 

Circ.     1884.     xxxviii.,  p.  175. 
BiGELow. — A  Case  of   Oophoritis.     Cincin.   Lancet   and   Clinic.     1884.     xxii., 

P-  377- 
Bournand. — De  I'ovarite  blenorrhagique.     Par.,  1847. 
BouvERET. — Ann.  de  Gynec.     iv.,  p.  427. 

CouRTv. — Diseases  of  the  Uterus.     (Trans,  by  A.  McLaren.)     1882.     P.  510. 
Duncan. — Ed.  Med.  Journ.     Sept.,  1871. 

Gallard. — De  I'ovarite  aigue  at  de  la  congestion  pelvienne.   France  Med.    1884. 
i.,  p.  614. 
Gaz.  des  hop.     July-October,  1869. 
Hawkins. — Removal  of  Ovaries  and  Fallopian  Tubes  for  Ovaritis.     Denver 

Med.  Times.     1883-4.     iii.,  p.  289. 
Imlach. — Specimens   of    Infl.    Disease   of    Ovaries,    &c.,    from    21    women. 
Liverpool  Med.-Chir.  Journ.     1885.     v.,  p.  221. 
Ovarian    Abscess    and    Pyosalpinx.      Liverpool    Med.-Chir.    Journ. 
Jan.,  1886. 


BIBLIOGRAPHY.  769 

Lettule. — Ovarite  suppuree     .     .     .     pelvi-peritonite     .     .     .     mort.     Ann. 

de  Gynec.     Par.,  1884.     xxii.,  p.  442. 
LusK. — Ovaritis  with  Abscess.     Amer.  Jotirn.  Obstet.     Jan.,  1880. 
Macdonald. ^Gonorrhoea!  Ovaritis.     Edin.  Med.  jfourn.     Dec,  1885. 
Nagel. — Centralbl.  f.  Gynclh.     1887.    No.  26.    And  Lond.  Med.  Rec.    July  15th, 

1887. 
PuECH. — Gaz.  des  hop.     i860.     P.  517.     (Abscess  bursting  into  peritoneum.) 
Raciborsky. — Gaz.  des  hop.     Nov.,  1856. 
ScHROEDER. — Diseascs  of  the  Female  Sexual  Organs.     (Ziemssen's  Cyc.)     1875. 

P-  351- 
ScnvLTZY-.—Jenaische  Zeit.  f.  Med.  n.  Nat.  i.     1864.     P.  279. 
Slavjansky. — Arch.f.  Gynaek.     Vol.  iii.,  p.  183. 
Tait. — Diseases  of  the  Ovaries.     4th  Ed.     1883.     P.  87. 
Tilt. — Diseases  of  Menstruation  and  Ovarian  Inflammation.     1850. 

Diagnosis  of  Subacute  Ovaritis.     Anier.  Med.  jfourn.     Vol.  Ixvii. 
Verjus. — Theses  de  Paris.     1884.     (Abscess  bursting  into  peritoneum,  causing 

death.) 

DISPLACEMENTS   OF   THE    OVARY. 

Atthill. — Prolapse  of  Ovaries.     Bled.  Press  and  Circ.     Dec.  loth,  1880. 
Barnes. — On  Hernia  of  the  Ovary.     Amer.  Journ.  Obstet.     Jan.,  1883. 
Chambers. — Congenital  double  Inguino-Ovarian  Hernia.    Lond.  Obstet.  Journ. 

Dec,  1879. 
Cleveland. — Adhasion    und    Prolapsus    des    Ovarien.      Schmidt's  Jahrbuch. 

v.,  156. 
Deneux. — Sur  la  hernie  de  I'ovaire.     Par.,  1813. 
Englisch. — Medicinische  Jahrbi'tcher.     1871.     P.  335. 
GooDELL. — Prolapse  of  Ovaries.     Lessons  in  Gynecology .     Phila.,  1880. 
Guersant. — Bull,  de  Therap.     28.     1865.     Two  cases.     Operation. 
Holmes. — Lancet.     Jan.,  1884.     Operation. 

Hunter. — Prolapsus  of  the  Ovary.     Phila.  Med.  Times.     1883-4.     xiv.,  p.  559. 
luTZE. — Displacement  of  Left  Ovary.     Battey's  Operation.     Death.     Amer. 

Pract.     1883.     xxviii.,  p.  257. 
Jones    (W.    M.) — Congenital   Hernia  of  both   Ovaries.      Brit.   Med.   Jotirn. 

Sept.,  1877. 
Lassus. — Path.  Chir.     Par.,  1806.     ii.,  p.  98.     Operation. 
LoEPER. — Monatschr.  f.  Geb.     B.  28,  p.  453.     Operation. 
Lol'maigne. — De  la  hernie  de  I'ovarie.     Par.,  1869. 
McBuRNEY. — Hernia,  removal.     Ann.  of  Surg.     July,  1887. 
McCluer. — Amer.  Journ.  Obstet.     vi.,  p.  613.     Operation. 
Meadows. — Trans.  Lond.  Obstet.  Soc.     iii.,  p.  438.     Operation. 
MuLERT. — Journ.  f.  Chirurg.     1S50.     ix.,  p.  3. 

Munde. — Prolapsus  of  the  Ovaries.     Med.  Times  and  Gaz.     Jan.,  1880. 
Neboux. — Bull,  de  Therap.     Avril,  1845.     Operation. 
Pott. — Hernia    of    Ovaries    successfully    operated    upon.     Works.     Vol.   ii. 

(Occurred  in  1756.) 
PuECH. — Des  hernies  de  I'ovarie.     Gaz.  Obstet.  de  Par.     1875. 
Skene. — Prolapse  of  Ovaries.     Amer.  Journ.  Obstet.     April,  1879. 
Heywood  Smith. — Hernia  of  the  Ovary.     Brit.  Gynac.  Journ.     Nov.,  1885. 
Stocks. — Ovarien  Prolaps.     Centralbl.  f.  Chir.     v.,  i. 
Weinlechner  and  Balleray. — Ovarial-hernie.     Centralbl.  f.  Chir.     v.,  p.  5. 

1877. 
Werth. — Doppelseitige  Hernia  Ovarialis  inguin.     Arch.f.  Gynaek.     v.,  p.  11. 

cystic  and  cirrhotic  ovaries. 

Beraud. — (Variolous  ovaritis.)     Archiv.  Gen.  de  Med.     1859.     xiii.,  p.  588. 
Brown. — Cystic  Ovaries  removed  by  Laparotomy.     Hydrosalpinx.    New  York 

Med.  Rec.     1884.     xxv.,  p.  195. 
Jacobi. — Cystic  Ovaries.     Battey's  Operation.     New  York  Med.  Rec.     18S4 

XXX.,  p.  705. 

50 


770  BIBLIOGRAPHY. 

Tait. — Diseases  af  Ovaries.     4th  Ed. 

Wallace. — Bilateral   Ovarian   Cystic   Degeneration.      Oper.     Rec.     Lancet. 

1884.     i.,  p.  1027. 
Will. — Cystic  Degeneration  of  the  Ovary.      Battey's   Operation.      Death. 

Peoria  Med.  Monthly.     1883-4.     iv.,  p.  419. 


DISEASES    OF    THE    FALLOPIAN    TUBES. 

AVELING. — A  Case  of  Double  Pyosalpinx.     Brit.  Gyncsc.  Journ.     July,  1885. 
BoLDT. — Interstitial  Salpingitis.     Amer.  Journ.  Obstet.     xxi.     Feb.  1888. 
Brossard. — Tubo-ovarite   suppuree   avec    peritonite    pelvienne   circonscrite. 

Ann  de  Gynec.     Par.,  1885.     xxiv.,  p.  117. 
Chambers. — Hydro-salpinx.     New  York  Med.  Rec.     1885.     xxvii.,  p.  273. 
Chapman. — Extreme  Cystic  Dilatation  of  the  Fallopian  Tubes.     Abdominal 
Section.     Recovery.     Tr.  Edin.  Obst.   Soc,  1883-4.     ^''•>  P-  ^99-     Ldin. 
Med.  Journ.,  1884-5.     xxx.,  p.  204. 
VON  Dessaner. — Ibid,     xxvii.,  p.  60. 

Ferguson. — The  Diagnostic  Value  of  Ciliated  Columnar  Epithelium  in  cases 
of  Hydrosalpinx    and    Pyosalpinx.      New    York.    Med,    Journ.     1885. 
xli.,  p.  211. 
Forster. —  Wiener.  Med.  Woch.     1852.     Nos.  44  and  45. 
GooDELL. — Pyosalpinx  and   Hydrosalpinx.     Journ.   Amcr.  Med.  Ass.      1S84. 

iii.,  p.  24. 
Gusseraw. — Pyosalpinx,  31  cases.     Areh.f.  Gyn.     xxxii.,  2. 
Hennig. — Der  Katarrh  der  inneren  Weiblechen  Geschlechtstheile.     2nd  Ed. 
Horne. — Case  of  Salpingo-oophorectomy  for  Pyosalpinx.     Dublin  J.  Med.  Sc. 

1884.     Ixxvii.,  p.  347. 
Klob. — Path.  Anat.  d.  Weibl.  Sexualorganc.     p.  288. 
Lediard. — Pyosalpinx.       Abdominal     Section.      Recovery.      Lancet.       1884. 

ii.,  p.  493. 
Macdonald. — Two     cases    of    Salpingo-oophorectomy.      Ed.    Med.    Journ. 

1884-5.     xxx.,  p.  97. 
Martin. — Successful  Operation  for  Pyosalpinx.     Boston  Med.  and  Surg.  Journ. 
1884.     cxi.,  p.  132. 
Salpingitis.     Zeit.  f.  Geb.  u.  Gyndk.     xii.,  2. 
Porter. — Report  on  a  case  of  Pyosalpinx.     Phila.  Med.  News.     1885.     xlvi., 

p.  362. 
Price. — Six    Operations   for   Pyosalpinx.      A''.   Y.  Med.   Journ.     1886.     xliv., 

P-  458. 
Sanger. — Gonorrhoeal  Disease  of  the  Uterine  Appendages,  and  the  Operative 
Treatment.     Abst.  in  Amer.  Journ.  of  Med.  Sc.     Jan.,   1885.      p.  295. 
And  letter  in  Obstet.  Gaz.     Cincinnatti.     Feb.,  1887. 
Simpson. — Hsemato-salpinx.      Tait's    Operation.       Trans.    Edin.    Obstet.   Soc. 
1883-4.     ix.,  p.  1S2. 

Hsemato-salpinx.     Case.     Tait's   Operation.     Edin.  Med.  Journ. 
1884.     xxx.,  p.  447. 
Tait. — Diseases  of  Ovaries.     4th  Ed. 

Tr.  Med.-Chir.  Soc.  Edin.     1883-4.     ii'-  P-  36- 
Trans.  Obstet.  Soc.  Lond.     1884.     Pp.  iix,  138,  234. 
New  Yorli  Med.  Journ.     1884.     xl.,  p.  421. 
Med.  Times  and  Gaz.     1884.     ii.,  p.  318. 
Edin.  Med.  Journ.     Sept.,  1885. 
Brit.  Gynac.  Journ.     July,  1885,  and  Nov.,  1885. 
Terrillon. — Hasmato-salpingitis.      Four   Operations.     Le  Bull.  Mdd.    June 

ist,  1887. 
Wagner. — Monatsschr.  fiir  Geb.     xiv.,  p.  436. 

WiEDOW. — Zur  Operativen  behandlung  der  pyosalpinx.     Centralbl.  f.  Gyndk. 
Leipz.,  1885.     ix.  p.  145. 

% 


BIBLIOGRAPHY.  771 

Wylie. — Cases  of  Salpingitis.     Results  of  Operations.     New  York  Med.  Rec. 

1S85.     xxvii.,  pp.  85,  161. 

Diseases  of  the  Fallopian  Tubes.     Boston  Med.  and  Surg.  Journ. 

1886.     cxii.,  p.  109.     Amer.  Jotirn.  Ohstet.     vi.,  p.  43. 
Zeiss. — Pyo- und   Hamato-salpinx.     Centralbl.  f.  Gyndk.     Leipz.     1885.     vii. , 

P-  745- 

OPERATIONS    FOR   CAUSES    RESIDING    IN    UTERUS. 

Battey, — Trans.  Internat.  Med.  Congress.     1881.     iv. ,  p.  280. 

Discussion  on  the  Treatment  of  Uterine   Myoma.       Brit.   Gyncec. 

Journ.     July  and  November,  1885. 
DuPLAY. — De  I'ablation  des  ovaires  dans  le  traitement  des  fibro-myomes,  &c. 

Archiv.  Gen.  de  Med.     July,  1885. 
Menzel. — Castrationen    bei   Ovarialprolaps.       Uterus-fibrom.       Retroflexio 

uteri  mit  Descensio  Ovariorum.     Archiv.  f.  Gynclk.     Bd.  xxvi.     Hft.  i. 
Tait. — Post-mortem  Examination  on  case  where  Appendages  were  removed 

for  Myoma  three  years  before  death.      Med.  Times  and  Gaz.      1884. 

ii.,  p.  147. 

The  Modern  Treatment  of  Uterine  Myoma.      Brit.  Med.  Journ. 

Aug.,  I^85. 
Werner. — Battey's  Operation  performed  in  a  case  of  Malformation  of  the 

Genital  Organs.     Am.  Journ.  Obstet.     1^84.     xvii.,  p.  144. 
WiEDOW. — (For  Fibroids.)     Archiv.  f.  Gynctk.     1S85.     Bd.  i.,  p.  299. 

ovarian  neuroses. 

BiRCHER. — Die  Castration  bei  Ovarial-neuralgie  und    Hysterie.      Cor.-Bl.  f. 

Schweiz.  Aerzte.     1S84.     xiv.,  pp.  447,  470. 
Brooks. — Castration  for  Hystero-Epilepsy.     Phila.  Med.  and  Surg.  Rep.    1885. 

iii.,  p.  230. 
Carstens. — Three  Cases  of  Battey's  Operation.     Itiid.,  p.  266. 
Geissler. — Hyperaesthesie  des  Ovarium.     Schmidt's  Jahrbuch.     v.,  p.  76. 
GooDELL. — Removal  of  Ovaries  for  Confirmed  Masturbation.      Phila.  Med. 

Times.     1883-4.     ^^'v.,  p.  230. 
Hegar. — Der   Zusammenhang    der    Geschlechtskrankheiten    mit    Nervosen 

Letden    und    die    Castration    bei    Neurosen.       Stuttgart,    1885,    and 

Centralbl.  f.  Gyncih.     1884.     xxxviii.,  p.  593. 
Homans — Hysteria  as  affected  by  Removal  of  the  Ovaries.     Boston  Med.  and 

Surg.  Journ.     1884.     ex.,  p.  542. 
Landau  and  Remak. — Ein  Fall  von  Ovariotomie  bei  hysterischer  Hernia- 

nasthesie ;    Klinischer   Beitrag    zur    Ovarie-    und    Castrations-Frage. 

Ztschr.  f.  Klin.  Med.     18S3.     vi.,  p.  437. 
Leppmann. — Castration  bei  Epilepsie  und  Hystero-Epilepsie.     Ibid. 
Montgomery. — Removal  of  Appendages  for  Menstrual  Epilepsy.    Phila.  Med. 

News.     1884.     xi^'i  584  ;  ^i^d  Amer.  Journ.  Obstet.     1S85.     xviii.,  152. 
MUNDE. — Removal  of  Appendages  followed  by  disappearance  of  symptoms  of 

Spinal  Atrophy.     Amer.  Journ.  Obstet.     1S84.     xvii.,  p.  1162. 
Ohr. — Genito-Reflex  Neuroses  in  the  Female.     Amer.  Journ.    Obstet.     1883. 

xvi.,  p.  50  et  seq. 
Fallen. — True   import   of  Oophorectomy  in    Epilepsy.      A^.    Y.   Med.   Rec. 

June  5th,  1880. 
ScHMALFUss. — Zur  Castration  bei  Neurosen.    Archiv.  f.  Gynak.    xxvi.  i.,    p.  1. 
ScHROEDER. — Dcutsclie  Mcd.  Zeit.     1886.     vii.,  p.  943. 

Zeit.  f.  Geb.  u.  Gynak.     xiii.,  2. 
Sims. — Battey's  Operation  in  Epileptoid  Affections.     N.  Y.  Med.  Rec.     June 

5th,  1880. 
Terries. — Sur  I'influence  que  peut  avoir  I'ovariotomie  sur  les  manifestations 

hysterique.     Bull,  et  Mem.  Soc.  de  Chir.  de  Paris.     1884.     x.,  p.  243. 
Walton. — Hysteria  as  affected  by  Removal  of  the  Ovaries.     Ibid.,  p.  529. 

50  * 


772  BIBLIOGRAPHY. 

GENERAL    CASES. 

Baker  (W.  H.) — The  Use  and  Abuse   of  Battey's   and   Tait's  Operations. 

Boston  Med.  and  Surg.  Journ.     1885. 
Battey. — Summary  of  15  Cases  of  Battey's  Operation.     Brit.  Med.  Journ, 

April  3rd,  1880. 
Chereau.^ — Memoire  pour  servir  a  I'etude  des  maladies  des  ovaries.   Par.  18S4. 
Chunn. — Removal  of  Uterine  Appendages.     Maryland  Med.  Journ.      1883-4. 

X.,  p.  526. 
Croom  (J.  H.) — Remote  Results.     Amer.  Journ.  Med.  Soc.     Dec,  1888. 
Dawson. — Two  Cases  of  Oophorectomy.     Amer.  Journ.  Obstet.     1884.     xvii., 

p.  964. 
Engelmann. — Case  of  Battey's   Operation.      Boston  Med.   and  Surg.  Journ. 

May  13th,  1880. 
Van  Ernag. — Four  Cases  of  Oophorectomy.     Kansas  City  Med.  Rec.     1884. 

i.,  p.  95. 
Ewens. — Two  Cases  of  Oophorectomy.     Brit.  Med.  Journ.     Jan.  31st,  iSSo. 
Fehling. — Zehn  Castrationen,  &c.     Archiv.  f.  Gynaek.     Berl.     1883-4.     xxii., 

p.  291. 
Gallard. — Physiologic   de   la   Menstruation.      Compt.   rend.       18S3-4.      ''"■t 

P-  713- 
Gardner. — Ovaries  and  Fallopian  Tubes   removed,  &c.      Canada  Med.  Rec. 

1882-3.     xi.,  p.  242. 
Goodell. — Two  Cases  of  Oophorectomy.     Phila.  Med.  News.      1884.      xiv., 

p.  468  ;  and  Amer.  Journ.  Obstet.     1S84.     xvii.,  p.  1186. 
Gray. — A  Case  of  Battey's  Operation.     Atlanta  Med.  and  Surg.  Journ.     1884. 

i.,  p.  321. 
Hegar. — Die  Castration  der  Frauen.     Samml.  Klin.    Vortr.      Leipz.      1878. 

Nos.  136-8. 
Hempel. — Indications.     Gottingen.     1886. 
Hermance. — Ovarian  Dysmenorrhoea  ;    Oophorectomy.     N.  Y.  Med.  Record. 

18S4.     XXV.,  p.  430. 
Hooper. — The  Morbid  Anatomy  of  the  Human  Uterus  and  its  Appendages. 

Lond.     1832.     (Specially  for  diseases  of  the  Fallopian  tubes.) 
Imlach. —  Six   Cases  of  successful   Removal    of    the    Uterine    Appendages. 

Liverpool  Med.-Chir.  Journ.     1884.     iv.,  p.  392  ;  also  ibid.,  Jan.,  1886. 
Jackson. — Double    Oophorectomy   for    Dysmenorrhoea,    &c.       Weekly    Med. 

Review.     Chicago.     18S4.     ix.,  p.  290. 

A  Contribution  to  the  Relations  of  Ovulation  and  Menstruation. 

Journ.  Amer.  Med.  Ass.     1884.     And  Reprint. 
Jacobi. — Salpingo-Oophorectomy.     A^.  Y .  Med.  Journ.     18S4.     xxxix.,  p.  673. 
Johnson   (J.  T.) — Four  Cases  of  Oophorectomy,  with  remarks.     N.  Y.  Med, 

Journ.     Sept.  26th,  1885. 
Keen. — Three  Cases  of  Tait's  Operation.     Phila.  Med.  Times,     xvi.,  p.  343. 
Keith    (Skene). — Twenty-three   Cases.      Edin.    Med.   Journ.       March    and 

April,  1887. 
Kyle. — Oophorectomy.     Louisville  Med.  News.     1S85.     xix.,  p.  129. 
Loewenthal. — Une   nouvelle   Theorie    de    la    Menstruation.       Med.   Pract, 

Par.     1884.     v.,  p.  577;  and  Semaine  Med.     Par.     1884.     iv.,  p.  461. 
LuTAUD. — Ovariotomie  Normale.     Arch.  Gen.  Med.     1879.     i. 
Meadows. — Ovarian  Menorrhagia.     Brit.  Med.  Journ.     July  12th,  1879. 
MuNDii. — Three  successful  Cases  of  Oophorectomy.     New  Eng.  Med.  Monthly. 

1883-4-     iii-  P-  549- 
Parish. — Removal  of  the  Uterine  Appendages.      Phila.  Med.  Times.      Jan. 

23rd,  1886. 
Prochownick. — Beitrage  zur  Castrations-frage.     Arhiv.  f.  Gynah.     XXIX.,  ii. 
Rabagliati. — Two  Cases  of  Double   Oophorectomy.      Lancet.      18S4.      ii., 

p.  1091. 
Reed. — Principles  of  Practice.     Journ.  Amer.  Med.  Assn.     I88S.     xi.,p.  253. 
Savage.— On  Oophorectomy.     Lond.  Obstet.  Journ.     May,   1880;  and  Traws. 

Internat.  Med.  Cong.     1881.     iv. 


BIBLIOGRAPHY.  773 

Simpson. — Ligature   of   Broad   Ligaments    instead   of    Battey's   Operation. 

Ediii.  Med.  Journ.     18S4-5.     xxx.,  p.  444. 
ScHLESiNGER. — These  de  St.  Petersbourg.     1887. 
De  SiNETY. — Ovulation  et  Menstruation.     Ann.  de  Gynec.     vii. 
Smith  (Greig). — Removal  of  the  Uterine  Appendages.     Bristol  Mcd.-Chiy. 

Journ.     1886. 
Taylor  (J.  W.) — Report  on  Abdominal  Surgery.    Birm.  Med.  Rev.    Sept.,  18S5. 
Thallon.— The    Battey-Tait    Operation.      N.    Y.    Arch.    Med.      1884.      xi., 

p.    iSo. 
Thomas. — Normal  Ovariotomy.     Amer.  Med.  Journ.     Ixvii. 
Thomas  (T.  G.) — Two  Cases  of  Extirpation  of  the  Ovaries.      Med.  Chron. 

Baltimore.     1883-4.     "■■  P-  ^^i. 
Verneuil  and  Ferrier. — Menstruation   after  Double   Ovariotomy.      Land. 

Obstet.  Journ.     v. 
Wells,  Hegar,  and   B.'^ttey. — Symposium.      Am.   Journ.  Med.  Sc.      xcii., 

P-  483- 
Wylie. — Fourteen  Operations.     Trans.  N.  Y.  Acad.  Med.     1SS6.     v.,  p.  99. 


HYSTERECTOMY   FOR   CANCER. 

Anderson. — Amer.  Journ.  Obstet.     1882.     xv.,  p.  322. 

Baker. — Comparison  of  Total   and   Partial   Amputation.     New    York   Med. 

Journ.     1886. 
Barnes  and  Garson. — Am.  Journ.  Obstet.     1882.     xv. 
Boeckel. — Fistula   of    Ureter.      Nephrectomy.      Gaz.    Med.    de    Strasbourg. 

Sept.,  18S4. 
Braithwaite. — Two  Cases.     Lancet.    July  23rd,  18S7. 
Brennecke. — Zeitschr.  f.  Geb.  u.  Gyn.      1886.      xii.,  p.  56;  and  Centralbl.  f. 

Gyndk.     1883.     vii.,  p.  763. 
Brown  and  Simpson. — Edin.  Med.  Journ.     18812.     xxvii.,  p.  745. 
Brit.  Med.  Journ.,  Leader  in.     1883.     ii.,  p.  S37. 
Buffet. — Forcipressure  to  Vessels.     Gaz.  des  hop.     1886.     lix.,  p.  647. 
CoE. — Annals  of  Surgery.     18S5.     ii.,  p.  486. 
Comet. — De  I'hysterect.  vag.  en  France.     Paris.     1886. 
Cotterell. — Brit.  Med.  Journ.     July  gth,  1S87. 
Demons. — Rev.  de  Chir.     August  loth,  1884. 

Duncan. — Extirpation  of  Uterus.     i885.     Reprint  from  Obstet.  Soc.  Trans. 
Edis. — Vaginal  extirpation.     Trans.  Ohstet.  Soc.     Lond.     1886.     xxvii. 
Emmett. — New  York  Med.  Joiirn.     1882.     xxxv.,  p.  627.  and  xxxvi.,  p.  61. 
Etheridge. — Three  Cases.     Obstet.  Gaz.     Cincin.     Dec,  1887. 
Fenger. — Amer.  Journ.  Med.  Sc.     1882.     Ixxxiii.,  p.  17. 
Foreman. — Austral.  Med.  Gaz.     1883-4.     iii.  p-  i43-      And  July,  18S5. 
Freund. — Trans.  Internal.  Congress.     1881.     iv.,  p.  323. 

GooDELL. — Vaginal  Hysterectomy.     N .  Y.  Med.  Journ.     i8S5.     xliii.,  p.  616. 
Gordon. — Three  cases.     Journ.  Am.  Med.  Ass.     1888.     xi.,  p,  296. 
VoN  Herff. — Archiv. /.  Gynrik.     1885.     xxvi.,  p.  i. 
Helmuth  (Freund). — Am.  Journ.  Obstet.     1882.     xv.,  p.  599. 
Hofmeier. — Zeit.f.  Geb.  u.  Gyn.     x.,  p.  269. 
Homberger. — Centralbl.  f.  Gyndk.     1882.     xxxi. 

Hyernaux  (New  inst.) — Bull.  Acad.  Med.     Belg.     1881.     xv.,  p.  827. 
Jackson. —  West.  Med.  Rep.     Chicago.     1882.     iv.,  p.  129. 
Journ.  Amer.  Med.  Ass.     August  15th,  1885. 
Trans.  Am.  Gyn.  Soc.     1883.     viii.,  p.  172. 
Jennings. — Lancet.     1886.     i.,  pp.  682,  825. 

Landau. — Seven  cases — forcipressure.     Berl.  klin.  Woch.     Mar.  5,  1888. 
VON  G.  Leopold. — Archiv.  f.  Gyniik.     Bd.     xxx.     Hft.  3. 
MacCormac. — Brit.  Med.  Journ.     1882.     ii.,  p.  91. 
Marchand. — Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Par.     1886.     xii.,  p.  152. 


774  BIBLIOGRAPHY. 

MoLiNES. — Coiitn'b.  a  I'etude  de  la  colpohysterectomie,  &c.     Montpelier.     i8S6. 
MuLEUR. — Clamp-forceps.     Noiiv.  Aych.  d'Obstet.  et  Gynec.     Aug.,  18S7. 
MuLLER. —  Wien.  Med.  Woch.     1884.     xxxiv.,  p.  213. 
MuNDE. — Med.  Times  and  Gaz.     May  7th,  1886. 
Polk.— iV.  Y.  Med.  Journ.     Aug.  25th,  1883. 
'  Post. — Internat.  Journ.  Med.  Sc.     Jan.,  1886. 
PuRCELL. — Vaginal  Hysterectomy.     Tr.  Obst.  Soc.     Lond.     1886.     xxvii. 

Brit.  Gynac.  Journ.     May,  1887. 
"  "  La;!t-rf.  Jan. 31st,  1885, andAug. 27th,  1887. 

RiCHELOT. — Union  Med.     1886.     xlii.,  pp.  85,  97,  217. 

And    others.       Discussion.       Bull,   et  Mem.   Soc.   Cliir.       1886. 
2nd  Sess.,  p.  375. 
RoHMER. — B71II.  et  Mem.  de  la  Soc.  de  Chir.     18S6.     xii.,  p.  947. 
VON  RoKiTANSKY. —  WicH.  Med.  Presse.     1S82.     xxiii.,  p.  657. 
Sanger. — Archiv.f.  Gyndk.     Bd.  xxi.     Hft.  i. 
Sauve. — Contribution  a  Vetitde  de  Vhysterectomie,  &c.     Paris.     1884. 
ScHATZ. — Archill,  f.  Gyndk.     Bd.  xxi.     Hft.  3. 
Schroeder. — Brit.  Med.  Journ.     1883.     ii.,  p.  520. 
Schultze. — Deutsche  Med.  Zeitung.     1886.     i.,  pp.  13,  25,  37. 
Simpson. — Edin.  Med.  Journ.     Nov.,  1882. 
Sinclair  (W.  J.)— Six  cases.     Med.  Chronicle.     Feb.,  1888. 
Stavde.— Deutsche  Med.  Woch.     Berl.     1886.     xii.,  pp.  601,  624. 
Stirling. — Brit.  Med.  Journ.     May  21st,  1887. 
Terrier. — Bull.  Soc.  de  Chir.  de  Par.     1886.     xii.,  pp.  11  and  467. 

Rev.  Gen.  de  Clin,  etde  Therap.     Nov.  8th,  1888. 
Terrillon. — Bull.  Soc.  de  Chir.  de  Par.     1886.     xii.,  p.  200. 
Trelat.— Ga^-.  des  h6p.     1886.     lix.,  p.  887. 
Wallace. — Brit.  Med.  Journ.     1883.     ii.,  p.  579. 
Wells.— BnY.  Med.  Journ.     1881.     ii.,  p.  856. 
Williams.— Cflsse/^s  Year-book  of  Treatment.     1885. 
Wylie.— (Modn.  of  Freund.)     Am.  Journ.  Obst.     1883.     xvi.,  p.  527. 


HYSTERECTOMY     FOR     MYOMA. 

Amiot. — Traitement  du  pedicle,  &.C.     Paris.     1884. 
Antal. — Congress  at  Buda-Pesth.     1880. 
Bantock. — Lancet.     1883.     i.,  p.  647. 

Trans.  Obstet.  Soc.     Lond.     1882-3-4-5. 
Barton. — Phila.  Med.  and  Surg.  Rep.     Jan.  31st,  18S5. 
Bayle. — Hysterectomie.     Diet,  des  Sc.  Med.     1883. 
BiGELOw. — Amer.  Journ.  Obstet.     Nov.,  1883,  et  seq. 
Billroth. — Wien.  Med.  Woch.     1S76,  i  and  2,  and  1877,  40. 
BoMET. — Acad,  de  Mid.     1870. 
Braithwaite. — Lancet.     1885.     i.,  p.  255. 
Clado. — De  Vhysterectomie  abdomitiale,  &c.     Paris.     1886. 
CouRTY. — Dis.  of  Uterus.     Trans.     Lond.     1882. 
Cutter. — Amer.  Journ.  Med.  Sc.     July,  1878. 
CzERNY. —  Wien.  Med.  Woch.     1881.     Nos.  18  and  19. 

Dudley. — Intra-peritoneal  elastic  lig.    Trans.  Amer.  Gymrc  Ass.     1886.    p.  458. 
Duncan. — Lancet.     Nov.  28th,  1S85. 
Duplay. — Ann.  de  Gynec.     Nov.,  1879. 
Frankel. — Enucleation.     Arch /.  Gyndk.     xxxiii.,  3. 
Fraipont. — Bull.  Soc.  Chir.     April  3rd,  1884. 
Fritsch, — Centralbl.  f.  Gyndk.     1879. 
Golding-Bird. — Lancet.     1882.     ii.,  p.  849. 
Goodell. — Phila.  Med.  Times.     1883.     p.  435. 
GussEROW. — Die  Neubildungen  des  Uterus.     Stuttgart.     1886. 


BIBLIOGRAPHY.  775 


Hegar. — Berl.  Klin.  Woch.     March  20th,  1876. 
Ccntralbl.  f.  Gyndk.     1880.     No.  12. 
Wien.  Med.  Presse.     1877.     No.  17. 
Hegar  und  Kaltenbach. — Operat.  Gyndk.     18S6. 
Herrgott. — (History.)     Rev.  Med.  dc  I'Est.     1885. 
HoMANS. — Lancet.     1883.     ii.,  p.  767. 

Boston  Med.  and  Surg,  journ.     1885. 
Hunter. — Air.er.  Journ.  Obstet.     1885.     p.  120. 
Jackson. — Brit.  Med.  Journ.     July  gth,  18S7. 
Johnson. — Am.  Journ.  Obstet.     1885. 
Jones  (S.) — Lancet.     1882.     i.,  p.  119. 
Kaltenbach. — Zeitschr.  f.  Gehurt.  u.  Gyn.     Bd.  x.     Hft.  i. 
Keith. — Tumours  of  the  Abdomen.     Pt.  i.     1SS5. 
Kleeberg. — Zeitschr.  f.  Gcb.  u.  Gyn.     1876.     No.  27. 
Koeberle. — Gaz.  Hebd.     Nov.  23rd,  1866. 

Gaz.  Med.     Strasbourg.     18S5. 

Allg.  Wien.  Med.  Zeit.     1885. 
KvsTETL.—Centralbl.  f.  Gynak.     1884. 

Lange. — Clinical  Aphorisms,  &c.     N.  Y.  Med.  Journ.     xliv.,  p.  19. 
Leopold. — ArcJiiv.f.  Gyn.     Bd.  xx.     Hft.  i. 
Lomer. — Zeitschr.  f.  Geburt.  u.  Gyndk.     Bd.  ix.     Hft.  2. 
Martin. — Berl.  Klin.  Woch.      1885.     No.  3. 

Path,  und  Therap.  der  Fraiien  Krankheiten.     Wien.     1885. 
Moeller. —  Berl.  Klin.  Woch.     1882.     No.  30. 
More-Madden. — Dub.  Journ.  Med.  Sc.     May,  1885.  , 

Brit.  Gyn.  Journ.     1885. 
Muller. — Gaz.  Med.  de  Strasbourg.     1886.     xv.,  p.  102. 
Pean. — Gaz.  des  hop.     1886.     lix.,  p.  950. 
Pean  and  Urdy. — Hysterectomy.     Paris.     1873. 
Petit  and  Boinet. — Diet.  Encyc.  des  Sc.  Med.     Art.  Gastrotomie. 
Pozzi. — Ligature  elastique.     Cong,  f rang,  de  Chir.     1886.     i,  p.  537. 
Savage. — Lond.  Obstet.  Joxmi.     1880. 
ScHROEDER. — Ziemsscu's  Cyclop,     x. 

Berl.  Klin.  Woch.     1885. 
Zeitschr.  f.  Geb.  u.  Gyn.     Bd.  v.  and  Bd.  viii. 
Schwartz. — Diet,  de  Med.  et  de  Chir.     Arts. :  Uterus,  Hysterectomie. 
Stimson. — Neu  York  Med.  Journ.     1884.     P.  642. 
Tait. — Brit.  Gynaec.  Journ.     1886.     ii.,  p.  211. 

Brit.  Med.  Jorn.     Oct.  3rd,  1885. 
Terrillon. —  Bull.  Soc.  Chir.     1883. 
Thiersch. — Centralbl.  f.  Gyndk.     1882.     No.  40. 
Thiriar. —Prwse  Med.  Beige.     18S4. 
Tillaux. — Acad,  de  Med.     Oct.  14th,  1S79. 

Bull.  Acad.  Med.     1SS5.     P-  G28. 
Walter. — Brit.  Med.  Journ.     1883.     ii.,  p.  718. 
Wiedow. — Arch.  gen.  de  MM.     July,  1885. 
Wolfler. —  Wien.  Med.  Woch.     1885.     xxv.,  p.  1493. 

hysterectomy  for  inversion  of  uterus. 

Choppin. — Ainer.  Jorn.  Med.  Sc.     1867. 

Denuce. — Acad,  de  Med.     Paris.     Nov.  9th,  1875. 

Traite  Clinique  de  V Inversion  uterine.     Paris.     1883. 
Donne. — Archiv.  de  Gyndc.     Jan.  7th,  1876. 
Valette. — Lyon  Med.     April,  1871. 


776  BIBLIOGRAPHY. 

CESAREAN     SECTION. 

OLD. 

Bandon. — L'ovotomie  Abdominale  ou  Operation  Cesarienne.     Paris.     1S73. 

BuRCKHARDT. — Sectio  Casaveu.     Halle.     1879. 

CoLLiNGS. — Lancet.     1886.     ii.,  p.  120. 

DoLAN. — Brit.  Med.  Jorn.     May  23rd,  1885, 

Favre. — Rupture  of  Uterus.     Rev.  Med.  de  la  Suisse  Rom.      1886.     vi.,  p.  626. 

Gaudin. — Archiv.  de  Tocologie.     Sept.,  1878. 

GoDEFROY. — De  la  gastro-hysterotomie.     Rev.  de  Therap.  Med.  Chir.     1869. 

Grunewald. —  Ueber  den  Kaiserschniit.     Miinchen.     1875. 

Harper. — Lancet.    1886.     ii.,  p.  119. 

Harris. — Amer.  Journ.  Obstet.    Jan.,  1879. 

Med.  Times  and  Gaz.     1882.     i.,  p.  620. 

Amer.  Journ.  Med.  Sc.     Oct.,  1885. 
Heister. — Gen.  Syst.  of  Surgery,     ii.,  p.  27. 
Huendorf. — Ueber  Kaiserschnitt.     Halle.     1867. 
Jenks. — Tr.  Amer.  Gyn.  Soc.     1886.     x.,  p.  172. 
Kinkead. — Dublin  Journ.  Med.  Sc.     1880. 

Lahs. — (With  Ovariotomy.)     Deutsch.  Med.  Woch.     Feb.  2nd,  187S. 
LusK. — Prognoses  of  C cesarean  Operations.     Amer.  Journ.  Obstet.     1880.     xiii. 
Maschke. — Ueber  den  Kaiserschnitt.     Berlin.     1874. 
Parish. — Phila.  Med.  News.     1886.     xlix.,  p.  413. 

Polk.— Surg.  Anat.  Gravid  Uterus.     N.  Y.  Med.  Journ.     May  3rd,  1884. 
Radford. — Several   Papers,   between   1851   and   1S68,   in   Land.   Med.   Gaz., 

Prov.  Med.  and  Surg.  Journ.,  and  Brit.  Med.  Journ. 
Rodenstein. — The  Origin  of  Csesarean  Section.     N.  Y.  Med.  Journ.     1872. 
XV.,  p.  358. 
Uterine  Sutures.     Am.  Journ.  Obstet.     1871.     iii.,  p.  577. 
Roussetus. — De  partu  Casareo,  &c.     Trans,  of  Caspar  Bauhin's  work. 
Simon. — Mem.  Acad.  Roy.  de  Med.,  Sec.     ii.,  p.  623. 
Smiles. — An  Essay  on  the  C(xsarean  Operation,     Edinburgh.     1853. 
Tarnier. — Bull.  Soc.  de  Chir.  de  PMr.     1871.     xi. 
Walton. — Cincin.  Clinic.     Feb.,  1878. 

NEW, 

Beumer. — Arch.f.  Gyndk.     Bd.  xx.     3. 

BiRNBAUM. — Arch.f.  Gyndk.     Bd.  xxv.     Hft.  3. 

Crede. — Arch.f.  Gyndk.     1886.     xxviii.     144 

Ehrendorfer. — Arch.  f.  Gyndk.     Bd.     xxvi.     i. 

Fasola. — Gazz,  de  din.     Turin.     1886.     xxiii.,  p.  369. 

Garrigues. — Am.  Journ.  Obstet.     1883.     xvi.,  p.  344 

GooDELL. — For  Cancer  of  Cervix.     Med.  and  Surg.  Rep.,  Phila.     ix.     No.  13. 

Harris. — Sanger-Csesarean.     Med.  News,  Phila.     1886.     xlix.,  p.  317. 

Caes.  Sect,  and  its  substitutes.     Internal.  Encyc.  Surg.     1886.     vi. 
Krukenberg. — Arch.f.  Gyndk.     Bd.  xxviii.     Hft.  3. 
Kehrer. — Arch.f.  Gyndk.  and  Med.  Times  and  Gaz.     1882.     i.,  p.  479. 

Arch.f.  Gyndk.     1885-6.     xxvii.,  p.  227. 
Leopold. — Deutsche.  Med.  Woch.     1886.     xii.,  p.  545. 

Arch.  f.  Gyndk.     1886.     xxviii.,  p.  97. 
Mv^STER.—Centralbl.f.  Gyndk.     1886.     x.,  p.  82. 
PoTOCKi. — Ann.  de  gynec.     Par.     1886.     xxv.,  pp.  280,  345,  416. 
Sanger, — Arch.f.  Gyndk.     1885.     xxvi.,  p.  2. 
Schauta. —  Wien.  Med.  Woch.     1886.     xxxvi.,  pp.  73,  loi,  136. 
Skutsch. — Archiv.  f.  Gyndk.     1886.     xxviii  ,  p.  131. 

PORRO'S     OPERATION. 

Arnott. — Trans.  Med.  and  Phys.  Soc.     Bombay.     1885.     vii.,  p.  48. 
Bartlett. — A  modification.     Journ.  Amer.  Med.  Ass.     1886.     vii.,  p.  385. 
Bazzotti  — (2nd  Porro).     Gaz.  med.  ital.  lomb.     Milano.     1886.     viii. 


BIBLIOGRAPHY  777 


BouDON. — Thei-ap.  Contemp.     Paris.     1886.     vi.,  p.  277. 
Braun. — Wieii.  Med.  Woch.     1S83.     Nos.  45,  46. 
Chiara. — Ann.  nniv.  di  med.  e  chir.     Milano.     1878. 

Ann.  d.  Obstet.     Milano.     1879.     &c. 
Chalot. — Modification.     Gaz.  hcbd.     1883.     v.,  pp.  265,  291,  315. 
Demaison. — Gaz.  hebd.  de  med.     Paris.     1880.     xvii.,  p.  534, 
Etheridge. — With  Myoma  Uteri.     Chicago  Med.  Journ.     1886.     liii.,  p.  494. 
Fehling. — Centralbl.f.  Gyniih.     1884.     No.  2.     And  Nov.  23rd,  1878. 
Fochier. — Lyon  Med.     1879.     xxxi.,  pp.  393,  473,  505,  675. 
Godson. — Brit.  Med.  Journ.     Jan.  26th,  1884. 

Lancet.     1884.     i.,  p.  142. 
Grossmann. — Modification.     Amer.  Journ.  Med.  Sc.     1883.     P.  477. 
Harris. — Amer.  Journ.  Med.  Sc.     April,  1885. 

Amer.  Journ.  Obstet.     1880,  et  alibi. 
Herman. — Med.  Time-^  and  Gaz.     1884.     ii.,  p.  219. 

HoFMEiER.  — Zur  Indicationstellung,  &c.  Deutsche  med,  Woch.  1886.  xii.,p.  513. 
Imbert  de  la  Touche. — Paris.     1878. 
Jones. — Trans.  Obstet.  Soc.     Lond.     1886.     xxvii.,  p.  4. 
King. — Amer.  Journ.  Obstet.     1884.     P.  348. 
Lucas-Championn;ere. — Bull.  Soc.  de  Chir.     18S6.     xii.,  p.  93. 
Lumpe. — Arch.  f.  Gyndk.     1884.     Bd.  xxiii.     Hft.  2. 
Mangiagalli. — Abst.  in  Am.  journ.  Med.  Sc.     July,  1884. 
Ann.  de  Obstet.     Milano.     1879  and  1880. 
'M.KV.rin.—Zeitschr.f.Geb.u.Gyn.     1884.     Bd.  x.     Hft.  i. 
Maygrier. — Paris.     1880. 

MuLLER. — Centralbl.  f.  Gynak.     March  2nd,  1878. 
Partridge. —  (Rupture.)     N .  Y .  Med.  Journ.     July  19th,  1884. 
Patterson. — With  Myoma.     Glasg.  Med.  Journ.     April,  1885. 
Pavvlik. — Papers  in  Wien.  Med.  Woch.     1S79,  1880. 

Petit. — Med.  Times  and  Gaz,     1882.     i.,  p.  359.     (From  Archiv.  Gen.  de  Med.) 
Pinard. — Ann.  de  Gyn4c.     Paris.     1879  and  1880. 
PoRRO. — Ann.  Univ.  de  Medicina.     Oct.,  1876. 
Riedinger. —  Wien.  Med.  Woch.     1879.     xxix.,  p.  537  et  seq. 
Savage. — Birm.  Med.  Rev.     Nov.,  1883. 
Slavjansky. — Rupture.     Paris.     i856. 
Simpson. — Edin.  Med.  Journ.     July,  1884. 

Spath. — Impl.  Roy.  Soc.  of  Vienna,  and  Wien.  Med.  Woch.     1878. 
Tait. — Two  Cases.     Brit.  GyuiFC.  Journ.     1886.     ii.,  p.  57. 
Taylor. — Amer.  Journ.  Med.  Sc.     1880.     Ixxx. ,  p.  115. 
Veit. — Zeit.f.  Geb.  n.  Gyndk.     1880.     v.,  p.  256. 
ViNC.'Ni. — Lancet.     Feb.  28th,  1885. 

Wassiege. — Bull.  acad.  roy.  de  med.  de  Belg.     Brussels,     1878. 
Wells. — Brit.  Med.  Journ.     June  nth,  1887. 


LAPARO-ELYTROTOMY. 

Baudelocque. — op.  Cesariennc,  Elytrotomie,  &c.     Paris.       1844. 
Edis. — Brit.  Med.  Journ.     Nov.  30th,  1878. 
Ganzinette. — Le  Bull.  Med.     June  ist,  1887. 
Garrigues. — Amer.  Journ.  Obstet.     1S83.     p.  33. 

Neii)  York  Med.  Journ.     Nov.,  1878.     And  Reprint. 
Gillette. — Am.  Journ.  Obstet.     1880.     xiii.,  p.  98. 
Hine. — Lancet.     Nov.  9th,  1878. 

Jewett. — Two  Cases.     Trans.  Amer.  Gyn.  Soc.     1886.     x.,  p.  344. 
Fallen. — New  York  Med.  Rec.     1878.     xiii.,  p.  286. 
Skene. — Annals  of  Surgery.     1885.     i.     No.  i. 

Amer.  Journ.  Obstet.     1876.     viii.,  p.  626. 

N.  Y.  Med.  Journ.     1874.     xx.,  p.  401. 


778  BIBLIOGRAPHY. 


Thomas. — Amer.  Journ.  Obstet.     1S70.     iii.,  p.  125. 

Ibid.     1875.     ix.,  p.  326. 

Trans.  N.  Y.  Obstet.  Soc.     1879.     i.,  p.  354. 
Vella. — Gastro-elitrotomia.     Morgagni.  Napoli.     1857. 


OPERATIONS     FOR     ECTOPIC     GESTATION. 

Adam  and  O'Hara. — Austral.  Med.  Journ.     Aug.  15th,  1887. 
Adams. — Opern.     Gaz.  Med.  de  Paris.     1871.     xxvii. 
Atlee. — Amer.  Journ.  Med.  Se.     Oct.,  1878. 

Barbour. —  Case.     Frozen  Section.     Edin.  Med.  Journ.     Sept.,  1882. 
Bard. — Med.  Obscrv.  and  Enquiries.     Lond.     1764. 
BoNiLLY. — Soc.  de  Cliir.  de  Par.     Dec,  1886. 

Bratton. — Double  Uterus.  Opern.  Trans.  S.  Carolina  Med.  Ass.     iS'6.     P.  61. 
Fifteen  years' standing.    Case.    Tr.  S.  Car.  Med.  Ass.    18S8.    P.  121. 
Breudel. — Opern.  Sth  month.     Centralbl.  f.  Gynhtik.     Oct.  13th,  1S83. 
Bruch. — Laparotomy.     Cure.     Le  Prog.  Med.     Dec.  iSth,  18S6.     And  Bull,  et 

Mem.  de  la  Soc.  de  Chir.     1S86.     xii.,  p.  887. 
Chambers. — Austral.  Med.  Gaz.     Sept.,  1885. 
Champneys. — Brit.  Med.  Journ.     Dec.  3rd,  1887. 
Cooke. — Lond.  Obstet.  Trans,     v. 

CzEMPiN.  —  Zwei  Falle,  &c.     Deutsche,  vied.  Woch.     1886.     xii.,  p.  466. 
DiONis. — Course  of  Chirurgical  Operations.     Eng.  Trans.     Lond.     1733. 
Doran. — Lancet.     1SS2.     ii.,  p.  944. 

Trans.  Obstet.  Soc.     1885.     xxiv. 
Dun-can.— Cases.     St.  Bart.'s  Hosp.  Rep.     18S3. 
Duncan  (M.atthews)  and  Mason.— Four  Cases.     Abst.  in  Med.  CJiron.     Feb., 

1885. 
East.man. — Operation.     Child   and  mother  alive.     Ain.  Journ.  Obstet.     1888. 

xxi.,  929. 
Godson. — Removal  by  vaginal  incision.     Brit.  Med.  Journ.     Dec.  3rd,  1S87. 
Harris. — Phila.  Med.  News.     May  21st,  1887. 
Hun. — Case.     Amer.  Journ.  Med.  Sc.     July,  1884. 
Ferguson. — North  Carolina  Med.  Journ.     i885.     xvii.,  p.  210. 
Freund. — Edin.  Med.  Journ.     Sept.,  Nov.,  Dec,  1883. 
Galabin. — Obstet.  Trans.     1S82.     xxiv.,  p.  141. 
Gervis. — Brit.  Med.  Journ.     1886.     ii.,  p.  818. 
Grandin. — Am.  Journ.  Obst.     1886.     xix.,  p.  244. 
Gregory. — Opern.     St.  Louis  Cour.  Med.     18S6.     xvi.,  p.  235. 
Hamon. — Paris  med.     18S6.     xi.,  p.  421. 
Harris. — Cystectomy  or  Cystotomy,  with  Living  and  Viable  Foetus.     Am. 

Journ.  Med.  Sc.     1SS8.     xcvi.,  p.  262. 
Jakins. — Austral.  Med.  Gaz.     1S85-6.     v.,  p.  271. 

Janvrin.     Case  of  Tubal  Pregnancy.    Trans.  Amer.  Gyn^^c.  Soc.    1886.    P.  471. 
Johnson. — Case  of  Operation.     New  York  Med.  Pec.     Feb.  26th,  18S7. 
Kelly. — Removal  of   Sac  and  contents.     N.   Y.   Med.   Journ.     1SS6.     xliii., 

p.  617. 
Langer. — Ein  Fall,  &c.     Griefswald.     1886. 

Leopold. — Med.  T.  and  Gaz.     18S2.     i.,  p.  41.     And  Arch iv.  f.  Gyniih. 
LiTTLEwooD. — Lancet.     1886.     i. ,  p.  36. 
LusK.— Bn7.  Med.  Journ.     Dec.  4th,  1886. 

Boston  Med.  and  Surg.  Journ.      1S86.     cxv. ,  p.  34. 
Macdonald. — Opern.     Resec  of  Gut.     Edin.  Med.  Journ.     Feb.,  1S84. 
McNaught. — Brit.  Med.  Journ.     Jan.  21st,  18S8. 
MKYGRi^R.—Terminaisons  et  traitement,  &c.     Paris.     18S6. 
Meadows. ^Discussion.     Obstet.  Trans,     xiii.,  xiv. 
Moullin.— 7ra;;s.  Obst.  Soc.     1S84.     xxv. 
Notta. — Opern.     7  years.     Prog.  Med.     May,  1884. 


BIBLIOGRAPH  779 

Oettinger. — Prog.  vied.     18S4.     xii.,  p.  196. 

O'Hara. — Opern.  for  Rupture.     Pliila.  Med.  News.     1886.     xlviii.,  p.  692. 
Parry. — Extra-Uterine  Pregnancy. 
Pennefather. — Lancet.    June  20th,  1863. 

Penrose. — Two  Cases.     Phila.  Med.  News.     18S8.     liii.,  p.  276. 
PiNARD; — Diet.  Encyc.  des.  Sc.  vied.     1886.     xi.,  p.  194. 
Price  (Joseph). — Two  Cases.     Reprint  from  Practice.     Phila.     Jan.,  1SS9. 
Rennert. — Archil',  f.  Gyndk.     1884.     No.  52. 
Robertson. — Opern.     Brit.  Med.  Joiirn.     Feb.  13th,  18S6. 
Rousseau. — Opern.     Union  med.     Sept.  30th,  187S. 
Sale. — Med.  Journ.     New  Orleans.     Oct.,  i860. 
Sinclair  (W.  ].)—Brit.  Med.  Journ.     Jan.  21st,  1888. 
Spanton. — Opern.     Brit.  Med.  Journ.     Jan.  12th,  1884. 
Spofforth. — Opern.     Brit.  Med.  Journ.     1886.     i.,  p.  154. 

'Tait. — Pathology  and  Treatment.     Brit.  Med.  Journ.     August  i6th,  1SS4,  and 
April  iSth,  18S5.     And  Lancet.     1S88.     ii.,  p.  409. 
Lectures  on  Ectopic  Pregnancy.     1S8S. 
Taylor. — Cincinnati  Lancet.     18S6.     xvi.,  p.  451. 
Thatcher. — Edin.  Med.  Journ.     Oct.,  1S82. 

Thomas.— Electric  Current.     N.  Y.  Med.  Journ.     Oct.  nth,  18S4. 
Thornton. — Obstct.  Trans.     1SS2.     xxiv.,  p.  81. 
Valentine. — N .  Y.  Med.  Journ.    Jan.  23rd,  18S6. 
YEiT.^Die  Eileiterschwangerscha/t.     Stuttgart.     1S84. 
Ward.— New  York  Med.  Rec.     Sept.  27th,  1S84. 
Werth. — Archiv.f.  Gynlik.     xxiv.,  p.  2. 

Deutsche  vied.  Woch.     Oct.  20th,  1887. 
Wiener. — Arch.  f.  Gynah.     18S5.     xxvi.,  p.  2. 
Williams. — Living  child.     Brit.  Med.  Journ.     Dec.  3rd,  1887. 


OPERATIONS     ON     THE     STOMACH. 

Barker. — Gastro-enterostomy.     Case.     Brit.  Med.  Journ.     Feb.  13th,  1886. 
Barwell. — Gastrostomy.     Case.     Brit.  Med.  Journ.     Dec.  5th,  1885. 
Bertoye. — Gastrostomie  et  dil.  dig.  du  pylore.     .     .     .     Lyon  Med.      1S86. 

Hi.,  p.  76. 
Billroth. — Clin.  Surgery.     New  Syd.  Soc.     1881. 

Coats  and  M.aylard. — Pylorect.     Case.     Brit.  Med.  Journ.     July  24th,  1886. 
Cohen. — Recherches  sur  le  manuel  op.  de  la  gastrostomie.     Tlicrap.  Contemp. 

Par.     1886.     vi.,  p.  323,  et  seq. 
Chavasse. — Gastrostomy.     Lancet.     1886.     i.,  p.  388. 

Golding-Bird. — Jejunostomy.     Case.     Brit.  Med.  Journ.     Dec.  5th,  1885. 
Gross. — Gastrostomy,  &c.     Anicr.  Journ.  Med.  Sc.     July,  1884. 
Von  Hacker. — Die  viagenoperationen  an  Billroth' s  Klinik.     Wien.     1885. 
Idelson. — Cases    of    Gastrostomy   in   Russian    Journals.     Lond.   Med.    Rec. 

July,   1886. 
KvH.—Uebcr  die  Resection  des  Pylorus.     Berlin.     1882. 
Lauenstein. — Zur  technik  der  Pylorus  resection.     Verhand.  d.  deutsch.  Gesell. 

f.  Chir.     1885.     xiv.,  p.  loi. 
Leuf. — Stomach,  Anatomy,  &c.     Phila.  Med.  News.     April  i6th,  1887. 
LuTZ. — Technique  of  Gastrectomy.    St.  Louis  M.  and  S.  Journ.     1882.     P.  380. 
Maydl. — Ueber  Gastrostomie.     Wien.  vied.  Bl.     1882.     v.,  p.  449,  et  seq. 
McBurney. — Pyloric  Stenosis.     Two  Operns.     New  York  Med.  Journ.    Jan. 

i6th.  1886. 
McGill. — Gastrostomy.     Two  Cases.     Lancet.     18S1.     ii.,  p.  942. 
Mikulicz. — Pylorect.     Case.     New  York  Med.  Rec.     Oct.  27th,  18S3. 
Morgan. — Gastrostomy  in  boy  aged  4.     Brit.  Med.  Journ.     Dec.  5th,  1S85. 
Morse. — Gastro-enterostomy.     Case.     Brit.  Med.  Journ.     March  13th,  1886. 
MuRiE. — De  la  resection  du  pylore,  6<,c.     Paris.     1883. 


780  BIBLIOGRAPHY 

Petit. — Sur  quelques  points  de  I'histoire  de  la  Gastrostomie.     Union  Med. 

1884.     xxxvii. 
PoLAiLLON.— Gastrotomy  for  fork.     Bull.  Acad,  de  Med.     1886.     xvi.,  p.  240. 
RocKWiTZ. — Gastro-enterostomie.     Deutsche  zeit.  f.  Chir.     Bd.  xxv.     Hft.  6. 
Ryan. — Gastrostomy  with  tracheotomy.    Austral.  Med.  Gaz.     1885.    v.,  p.  271. 
Schramm. — Pylorectomy.     Success.     Centralbl.  f.  Chiv.     1887.     xii. 
Stonham. — Gastrostomy  with  tracheotomy.     Lancet.     1886.     ii.,  p.  625. 
Street   (for  Kocher). — Pylorectomy.     Three  Cases.     Zeit  f.  Chir.     xxvii., 

5  u.  6. 
Tansini. — Pylorectomy.     Abst.  in  Lond.  Med.  Rec.     Nov.  15th,  1887. 
Thornton. — Gastrostomy  for  mass  of  hair.     Lancet.     Jan.  19th,  1886. 
WiNSLOw. — Operations  for  Pyloric  Stenosis.     Amer.  Journ.  Med.  Sc.     April, 

1885. 
WoLFER. — Zur  Resektion   des   Carcinomatosen   Pylorus.     Wien.  vied.  Woch. 

1882.     xxxii. 
Zesas. — Gastrostomie  und  ihre  Resultate.     Arch.  f.  Klin.  Chir.      1885.     Bd. 

xxxii.     Hft.  I. 


OPERATIONS   ON   THE   INTESTINES. 

Ashhurst. — Intestinal  Obstruction.     Internat.  Encyc.  Surg.     1886.    vi.     And 

Phila.  Polyclinic.     1885-6.     iii.,  p.  157. 
Ball. — Dub.  Journ.  Med.  Sc.      1886.     Ixxxii.,  p.  265. 
Ballance. — Colectomy.     Lancet.     1883.     ii.,  p.  5^5. 
Banks. —  Resect,  of  Gangrenous  Intest.     Med.  Times  and  Gaz.    May  2nd,  1885. 

Treatment  of  Intest.  Obst.     Lancet.     1885.     i.,  p.  39. 
Barker. — Intest.  Obst.     Opern.     Brit.  3Ied.  Journ.     1886.     i.,  p.  445. 

Opern.  for  Intussusception.     Lancet.     1S88.     ii.,  p.  200. 
Barlow   and   Godlee. — Supp.   Appendicitis.     Opern.     Lancet.     Dec.   19th, 

1885. 
Bartleet. — Surg.  Treat,   of   Intest.   Obst.      Birm.  Med.  Rev.      18S3.      xiv., 

p.  221. 
Barton  — Portion  of  Colon  removed  with  Tumour.     Lancet.    May  24th,  1884. 
Bayliss. --Intussusception    in    Children.      Ant.   Journ.   Obstet.      1886.      xix., 

p.  1156. 
Bell. — Intest.  Obst.     Case.     Edin.  Med.  Journ.     April,  1886. 
Benham. — Intest.   Obst.      Diag.   and   Treat.      Brit.   Med.  Journ.      1S82.      ii., 

p.  165. 
Besnier.— Dfs  etranglements  internes  de  Vintestin.     Paris,     i860. 
Blum. — De  la  resection  de  I'estomac.     Arch.  gen.  de  vied.     18S2.     cl.,  p.  332. 
Braun. — Operat.  Treat,  of  Intussusception.     Archiv.f.  klin.  Chir.     Bd.  xxxiii. 
Hft.  2. 
Operation  for  Intussusception.     Archiv.f.  klin.  Chir.     xxxiii.,  p.  2. 
Brinton. — Intestinal  Obstruction.     London.     1867. 

Bristowe. — Malig.  Dis.  of  Caecum.     Cases.     Med.  Times  and  Gaz.     July  4th, 
1885,  et  seq. 
Obstruction  of  the  Bowels.     Reynolds  Syst.  Med.     iii. 
Bryant. — Papers  on  Intest.  Obstruction  in  Med.  Times  and  Gaz.,  1872,  and 
Brit.  Med.  Journ.     1884. 
Colectomy.     Brit.  Med.  Journ.     18S2. 
BuRCHARD. — Treatment,  Med.  and  Surg.,  of  Acute  Peritonitis.     N.  Y.  Med. 

Journ.     August  15th,  1885. 
Byrd. — Artificial  Anus.     Rad.  cure.     Phila.  Med.  News.     18S4.     xliv. 

Enterectomy.     N.  Y.  Med.  Rec.     18S2.     xxii.,  p.  163. 
Chanternesse. — Obst.  intest.  guerison  par  le  lavage  de  I'estomac.     France 

vied.     1885.     i.,  p.  339. 
Chew. — Oblique  Resection.     New  Orleans  Med.  and  Surg.  Journ.     18S6.     xiv., 
p.  218. 


BIBLIOGRAPHY.  781 

CouPLAND. — Stricture  of  Intestine,  &c.     Brit.  Med.  Journ.     1878.     i.,  p.  122. 
Davies-Collev. — Colotomy,  delayed  opening.    Clin.  Soc.  Trans.    1885.    p.  204. 
Doyen. — Internal  Strangulation.     Union.  Med.     Reims.     1686.     x.,  p.  89. 
DuPLAY. — Du  traitement  chir.  de  I'occlusion  intestinale.     ArcJiiv.  gen.  de  med. 

1879.     cxliv.,  p.  709. 
Eastman. — Colectomy.     Journ.  Amer.  Med.  Assn.     Dec.  31st,  18S7. 
Edmunds. — Gastro-colic  fistula.     St.  Thos.  Hasp.  Rep.     xiii.,  p.  91. 
Fagge. — Intest.  Obstruct.     Kneading.     Cure.     Lancet.     1872.     ii.,  p.  in. 
Fenwick. — 125  Cases  of  Perforation  of  Appendix.      Cincin.  Lancet.      March 

2Sth,  1885. 
Fleming. — Resect,  of  Gangren.  Intest.     Lancet.     Sept.  loth,  1887. 

Obstruct,  of  Intest.  cured  by  Stomach-pump.     Med.  T.  and  Gaz. 
1866.     i.,  p.  413. 
Foley. — Cascotomy  for  Dysentery.     Cong,  franc,  de  chir.     1885. 
Forest. — Intussusception  in  Children.     Am.  Journ.  Obst.     1886.     xix. 
Fuller. — Resect,  of   Intest.      Three   Cases.      New    York   Med.   Rec.      1882. 

ii.,  p.  430. 
Gaston. — Surgery  of  Ileo-caecal  Connections.     Pamphlet.     18S7. 
GoLDiNG-BiRD. — Jejunostomy.     Brit.  Med.  Journ.     1SS5.     ii-.  P-  1063. 
Gould. — Unusual  cause.    Obstruction.     N.  Y.  Med.  Rec.     1886.    xxx.,  p.  443. 
Gross. — Scirrhus  of  Colon.     Laparotomy.     Phila.  3Ied.  Times.     Nov.  28th,. 

1S85. 
Habershon. — Diseases  of  the  Abdomen.     Lond.     1885. 
VoN    Hacker. — Pylorectomy  and  Gastro-enterostomy.      Arch.  f.   klin.  Chir. 

18S5.     xxxii. 
Hahn. — Colectomy  and  Enterectomy.     (Abst.)     Med.  Chron.     Nov.,  1887. 
Hall. —Peritonitis   from    Appendicitis.      Opern.     N.   Y.   Med.   Journ.     June 

i2th,   1SS6. 
Hardie. — Enterectomy  for  Intest.  Fistula.     Case.     Med.  Chron.     Jan.,  1885. 
Harris. — Suture  of  Appolito.     Med.  News,  Phila.     xlix.,  p.  445. 
Haslam. — Resection  and  Suture  of  Intestine.     Birm.  Med.  Rev.     Feb.,  1887. 
Henrot. — De  la  valcur     .     .     .     du  taxis  abdominal,  &c.     Reims.     1883. 
Henrotin. — Resection  for  Fistula.     Journ.  Amer.  Med.  Ass.     Dec.  5th,  1887. 
Hutchinson. — Notes  on  Intest.  Obstruction.     Brit.  Med.  Journ.     1878.     ii., 

P-  305- 
Obstruction.      Taxis.      Recovery.      Med.   T.  and  Oaz.     1872. 
ii.,  p.  652. 
III. — Resect,  of  Intest.     Two  Cases.     New  York  Med.  Rec.     Oct.  27th,  1883. 
Jennings. — Expts.  on  Intest.  Resect.     Lancet.     Nov.  22nd,  1884. 
Jessett. — Cancer  of  Alimentary  Canal.     London.     1886. 
Jones,  S.  —  Resect,  of  Gangrenous  Intest.     Lancet     Oct.  3rd,  1885. 
Kelsey. — Colotomy.     Amer.  Journ.  Med.  Sc.     Oct.,  18S5. 
Kocher. — Resection  of  5  ft.  of  Intestine.     Corrcsp.  Blatt.     March  ist,  18S6. 
Kronlein. — Enterostomy.     Case.     Berl.  klin.  Woch.     1879.     Nos.  35,  36. 
Kussmaul. — Heilung  von  Ileus  durch  magenausspulung.     Bcrl,  klin.    Woclt. 

1S84.     xxi.,  pp.  609,  6S5. 
Lammiman. — Colectomy.     Lancet.     Aug.  4th,  1883. 
Le  Moyne. — Contrib.  a  I't'tude  de  I'occlusion  intestinale     Paris.     1S7S. 
Leveque. — De  I'occlusion  intest.  prod,  par  les  rotations,  &c.     Paris.     1S85. 
Lloyd. — Sigmoid  Colotomy.     Lancet.     June  21st,  1884. 
McArdle. — Enterectomy.     Case.     Trans.  Roy.  Acad,  of  Med.     18SS. 
Macleod. — Intest.  Obstruction,  &c.     Brit.  Med.  JoJirn.    1876.    ii.,  pp.  643,  705. 
Madelung.— Modn.  of  Colotomy.     Lond.  Med.  Rec.     1884.     P.  345. 
Makins.— Artificial  Anus.     Resection.     St.  Thos.  Hasp.  Rep.     1884.     P.  181. 
Malins. — Laparo-enterotomy.      Two  cases.     Brit.  Med.  Journ.      1883.      ii., 

p.  581. 
Marcy. — Operns.  for  Intest.  Obst.    Boston  Med.  and  Surg.  Journ.     1886.     cxv., 

p.  79. 
Marshall. — Colectomy.     Lancet.     May  6th,  1SS2. 
McGuiRE. — Intest.  Obstruction.     Pepper's  Syst.  Tract.  Med.    Phila.    18S5.    ii. 


782  BIBLIOGRAPHY. 

Morris. — Various  papers.     Brit.  Med.  Joimi.     1884.     ii. ,  p.  1075.     And  1885 

i.,  p.  311. 
NicoLAYSEN.— Colectomy.     Case.     Med.  Times  and  Gaz.     1882.     ii.,  p.  360. 
Obalinski. — Laparotomie  bei  int.  Darmokklusion.     Wien.  Med.  Press.     1886, 

xxvii.,  p.  140. 
Parker. — Resect.  9  in.   for  Gangrene.     Trans.  S.  Carolina  Med.  Ass.     1886. 

P.  73- 
Parker,  R. — Intestinal  Obstruction.     Brit.  Med.  Journ.     1883.     ii.,  p.  669. 

Resect,  for  Gangrene.     Brit.  Med.  Journ.     Jan.  22nd,  1877. 
Peyrot. — De  I' intervention  chir.  dans  V  obstruct  de  l' infest  in.     Paris.     1880. 
Pilcher. — Indications  for  Opern.   in  Intest.   Obst.     Ann.  Surg.     1886.     iii., 

p.  214. 
Porter. — Artificial   Anus.     Closure.      Boston  Med.  and  Surg.  Journ.      1886. 

cxv.,  p.  80. 
PoRTEUS. — Invagination,    Sloughing.      Rec.      Gaillard's  Journ.      New  York, 

1886.     xlii. ,  p.   135. 
PosTEMPSKi. — Resez.  d'intestino.     Bull.  d.  Reale  Accad.  Med.     Guigno.     1886. 
PouLET. — Treatise  on  Foreign  Bodies.     Wood's  Series.     New  York. 
Prati. — Resection  of  Gangrenous  Intest.    Case.    Lond.  Med.  Rec.    1884.    P-  8. 
Rand. — Diagnosis  of  Course  of  Bowel.     Brit.  Med.  Jonrn.     18S3.     ii.,  p.  581. 
Reichel. — Zur  Diagnostik  und  Therapie  des  Ileus.    Deutsche  Med.-Zeit.    1884. 

ii.,  pp.  471,  483,  495. 
Richter. — Resect,  of  Strictured  Bowel.     Centralbl.  f.  Chir.     18S2. 
Roser. — Zur  Laparotomie  bei  Ileus.     Deutsche  ined.  Woch.     18S6.     xii. ,  p.  86. 
Schramm. — Laparotomy  for  Intest.  Occlusion.     Three  Cases.    Archiv.f.  Klin. 
Chir.     Bd.  XXX.     Hft.  4. 
Two  Laparotomies  for  Invagination.    Centralbl.  f.  Chir.    1887.    xii. 
Smith  (Thos.) — Removal  of  Gall-stone.     Lancet.     Dec.  3rd,  18S7. 
Thomas. — Intestinal  Disease  and  Obstruction.     Lond.     18S3. 
Treves. — Anat.  of  Intest.  and  Peritoneum  in  Man.     Lond.     1885. 
Intestinal  Obstruction.     Lond.     1883. 
Resection  of  Intestine's.     Med. -Chir.  Trans.     18S6. 
Truc. — Traitement  Chir.  de  la  Peritonite.     Paris.     18S6. 

Verneuil. — New  Method  of  Colotomy.     Phila.  Med.  Times.     May  i6th,  1885. 
Walker  (E.  D.) — Removal  of  Spoon  from  Small  Intestine.    Cinein.  Lancet  and 

Clinic.     Dec.  loth,  1887. 
Walker  (H.  O.)— Two  Resections  for  Gangrene.     Med.  Age.     Detroit,    Sept. 

26th,  1S87. 
Warren. — Process  of  Repair  after  Resection,  &c.     Trans.  Amer.  Surg.  Assn. 

1887. 
Weir. — Colectomy.     Case.     Table  of  Cases.     A''.  Y.  Med.  Journ.     Feb.  13th, 
18S6. 
Intestinal  Obstruction.     Ann.  Anat.  and  Surg.     Brooklyn.     1883. 
Wetekump. — Beitrage  zur  Lehre  vom  Ileus.     Berlin.     1883. 
Whitehead. — Ccecectomy  for  Epithelioma.     Brit.   Med.   Journ.     Jan.   24th, 

1585. 
WiNSLOW. — Intest.  Obst.     Opern.     Am.  Journ.  Med.  Sc.     1S86.     xci. 
Wood. — Fibroma  of  Caecum  ;  Enchondroma  of  Peritoneum.     Opern.   Lancet. 

1881.     i.,  p.  249. 
Wyeth. — Laparotomy  and   Intestinal   Suture.      N.  Y.  Med.  Journ.     March 

19th,  18S7. 
Wylie. — Suppurative  Peritonitis,  &c.     N.  Y.  Med.  Rec.     1886.     xxx.,  p.  553. 


OPERATIONS    ON    THE    KIDNEY. 

Special  Works. — Morris,  Bruce  Clarke,  Dickinson,  Roberts,  Ralfe,  Landau, 

Bartels,  Rosenstein,  Newman. 
Adams. — Nephrectomy.     Case.     Brit.  Med.  Journ.     1882.     ii.,  p.  1153. 
Agnew. — Nephrorraphy  and  Nephrectomy.     Phila.  Med.  Times.     July  13th, 

1885. 


BIBLIOGRAPHY.  783 

Baker  (Morraxt).     Nephrotomy.     Trans.  Loud.  Ivternat.  Congress,    ii.,  p.  262. 

Also  in  same  volume,  Barker,  Lucas,  Barwell,  and  others. 
Barker.  —  Cases  of  Opern.     Lancet.     1885.     i.,  pp.  95,  141. 

Lumbar  Nephrectomy.     Med.-Chir.  Trans.     1S81.     p.  257. 
Baum. — Statistics  of  Nephrectomy.     Phila.  Med.  Times.    Feb.  21st,  1885.    And 

Med.  and  Surg.  Rep.  Phia.     1888.     vol.  lix.,  p.  387. 
Von  Bergmann. — Nephrectomy.  Four  Cases.    Centralbl.  f.  Chir.   1884.  No.  45. 
Berkeley-Hill. — Nephro-lithotomy.     Lancet.     June  13th,  1S85. 
Billroth. — Nephrectomy.     Med.  Times  and  Gaz.     1884.     ii-'  P-  27. 
Boeckel. — Nephrectomy  for  Ureteric  Fistula.     Brit.  Med.  Jov.vn.     1884.     '•. 

p.  1262. 
Brosin. — Congenital  Sarcoma.     VircJiow's  Archiv.     Bd.  cxvi.     Hft.  3. 
Carter. — Renal  Calculus.     Liverpool  Med.-Chir.  Journ.     18S6.     vi.,  p.  480. 
Chiene. — Nephro-lithotomy.     Brit.  Med.  Journ.     1S85.     i.,  p.  2S0. 
Clarke  (Bruce). — Nephro-lithotomy,  &c.     Lancet.     Nov.  7th,  1885. 
Coupek. — Nephrectomy.     Med.  T.  ami  Gaz.     1880.     ii.,  p.  5S8. 
Croft. — Nephrectomy  for  Sarcoma.     Lancet.     May  23rd,  1885. 
Cullingworth. — Nephrectomy.     Sarcoma.     Med.  Chron.     1886.     v.,  p.  no. 
Dandois. — Tnmeiir  maligne     .     .     .     Operation.     Brux.     i!586. 
Davy. — Nephrectomy.     Case.     Brit.  Med.  Journ.     1884.     "•■  P-  757- 
Dickinson  and  Rouse. — Nephro-lithotomy.     Clin.  Soc.  Trans.     1SS5. 
Discussion  on  Nephrectomy,  Med.-Chir.  Soc.     Lancet.     18S0.     i.,  p.  402. 
Discussion  on  Nephro-lithotomy.     Lancet.     Feb.  19th,  1887. 
Duncan  (J.) — Nephrotomy.     Edin.  Med.  Journ.     July,  1S81. 
Dunning. — Nephrectomy.     Journ.  Amer.  Med.  Assoc.     Nov.  19th,  1887. 
Edis. — Sacculated  Kidney  removed.     Brit.  Gynac.  Journ.     iSS6.-     i.,  p.  408. 
Elder. — Nephrectomy.     Case.     Brit.   Med.  Journ.     18S2.     ii.,   p.   S35.     And 

two  Cases.     Lancet.     Aug.  ist,  1885. 
Gluck. — Diag.  of  unilateral  dis.     Centralbl.  f.  Chir.     1SS4.     ^O-  45- 
GoDLEE. — Nephrectomy  in  Lifants.     Paper  before  Clin.  Soc.     Lond. 
Grant. — Movable  Kidney.     Austral.  Med.  Journ.     Aug.  15th,  1887,^^5^^. 
Gross. — Nephrectomy.    Phila.  Med.  Times.    May2nd,  1SS5.    And  Amer.  Journ 

Med.  Sc.     July,  1885. 
Heilburn. — Beitrage  zur  Nephrektomie.    Centralbl.  f.  Gyncik.    1886.    xi.,  p.  1. 
Heineke. — Nephrotomy  and  Nephrectomy.    Von  Pitha  and  Billroth's  Surgery. 
HoLL. — Anomalies  of  12th  rib,  &c.     Langenbeck's  Archiv.     Bd.  xxv.     Hft.  i. 
Howard. — Suspected  Calculus.     Opern.     Lancet.     1886.     i.,  p.  1112. 
Imlach. — Cases   of  Nephrectomy.      Liverpool   Med.-Chir.   Journ.      1886.     vi., 

p.  478. 
Israel. — Nephrectomy.     Case.     Lancet.     1883.     i. 
KocHER. — Nephrectomy.     Deutsche  Zeit.  f.  Chir.     Bd.  ix.     Hft.  304. 
KuMMELL. — Nephrectomy.    Sarcoma.    Deutsche  med.Woch.    1886.    xii.,  p.  489. 
Lange. — Surg.  Anat.  of  Kidneys.     Ann.  of  Surg.     Oct.,  1885. 

Nephrotomy,   double,   and  Nephrectomy.     Cases.     Neiv  York  Med. 
Journ.     1886.     xliii.,  p.  108. 
Langenbuch. — Nephrectomy.     Case.     Berl.  klin.  Woch.     1877.     ^^o.  24. 
Le  Dentu. — Nephrectomy.     Archiv.  Gen  de  Med.     June,  1S84. 

Technique  de  la  Nephrectomie.     Rev.  de  chir.     1886.    vi.,  p.  104, 
And  others.     Discussion.     Mem.  ct  Bull,  de  la  Soc.  de  Chir.    1886. 
2e.  Sess.     p.  12S. 
Leopold. — Nephrectomy.     Archiv.  f.  Gyniik.     And  Med.  T.  and  Gaz.     18S2. 

ii.,  p.  558. 
Lloyd  (Jordan). — Observ.  in  Kidney  Surg.     Birm.  Med.  Rev.     Dec,  1886. 
Lossen. — Nephrectomy.     Lond.  Med.  Rec.     1881.     p.  i. 
Lucas. — Nephrotomy  and  Nephrectomy.    Brit.  Med.  Journ.    18S3.    ii,  p.  611. 

And  Ibid.     18S4.     i.,  p.  537. 
Maas. — Injuries  of  Kidney.     Lond.  Med.  Rev.     1878.     p.  421. 
Marshall. — Haematoma.     Puncture  and  Drainage.     Med.-Chir.  Trans.     1883. 
May  (Bennett). — Nephro-lithotomy.     Case.     Lancet.     1H83.     i.,  p.  278. 
Morris. — Methods  of  Operating.     Lancet.     1884.     1.,  p.  464. 


784  BIBLIOGRAPHY. 

MiNGES. — Primary   Malignant   Dis.   of    Kidneys.      Joiirn.   Amer.    Med.   Ass. 

June  6th,   1S85. 
Newman — Catheterization  of  Ureter.     Glasg.  Med.  Journ.     July,  1885. 
Ollier. — De  la  nephrectomie.       Bull.  acad.  de  vied.       1S83.     xii.,  p.  1077. 
Park. — Nephrectomy  on  Child.     Trans.  Am.  Surg.  Ass.     1886.     iv.,  p.  259. 
Paul. — Classification  of  Growths.     Brit.  Med.  Journ.     Jan.  12th,  1S84. 
PoLAiLLON.— Nephrectomy   for   Floating   Kidney.      France  med.      18S6.      ii., 

p.  966. 
Polk. — Movable  Solitary  Kidney  removed.     N.  Y.  Med.  Journ.     Feb.  17th, 

1883. 
Price. — Removal  for  Traumatism.    Tr.  Med.  Soc.  Pcnnsylv.    1888.    xx. ,  p.  200, 
Rawdon. — Nephrectomy  for  Rupture.    Liverpool  Med.-Chir.  Journ.    Jan.,  1884. 
Roberts. — Localising   Perinephric   Lesions.       Trans.  Am.  Surg.  Ass.     1885. 

ii.,  p.  518. 
Schmidt. — -Hysterectomy   and    Nephrectomy.      Milnchen  Med.   Woch.      1886. 

xxxiii.,  p.  701. 
Smith  (Th.) — Renal  Calculus.     Med.-Chir.  Trans,     liv.,  p.  211. 
Solomon. — Nephrectomy.     Calculous  pyelitis.     La  Gaz.  degli  Osp.    Aug.  31st, 

1884. 
Symonds.— Nephro-lithotomy.     Clin.  Soc.  Trans.     1885.     p.  180. 
Tait. — Surgery  of  Kidney.     Birin.  Med.  Rev.     July,  1884. 
Taylor  (J.  W.) — Rupture  of  Hydronephrosis.     Opern.     Lancet.     Oct.  4th, 

1884. 
Thomas. — Nephrectomy  for  Myxo-fibroma.     Am.  Journ.   Obstet.     18S2.     xv. 

Supp.  42. 
Thornton. — Nephrectomy.     Cases.     Lancet.     1883.     i.,  p.  899. 
Tiffany. — Nephro-lithotomy.     Case,     /liila.  Med.  Journ.     May  2nd,  1885. 
Torres. — Nephro-lithotomy.   Thermo-cautery.  Land.  Med.  Rec.    1879.   P.  229, 
Walter. — Nephrectomy  for  Cystic  Floating  Kidney.  Brit.  Med.  Journ.  1883. 

ii.,  p.  615. 
Weir. — Nephrectomy.     'New  York  Med.  Journ.     Dec.  27th,  1S84. 
Whitehead. — Nephrectomy  for  Sarcoma.     Lancet.     Aug.  15th,  1885. 
Wright. — Nephro-lithotomy.     Case.     Med.  Chron.     1886.     iv.,  p.  34. 


OPERATIONS   ON   THE   LIVER   AND    GALL-BLADDER. 

Alexander. — Cholecystotomy.      Case.      Liverpool  Med.-Chir.  Journ.      i885, 

vi.,  p.  221. 

Cholecyst.     8  pints  of  bile.     Ibid.     1888.     viii.,  p.  508. 
BoECKEL. — Cholecystotomie,   &c.     Mem.  Soc.   de  vied,   de  Strasburg.     1884-5. 

xxii.,  p.  126. 
BouiLLY. — Hepatic  hydatid  ;  rem.  by  laparotomy.     Bull.  Soc.  de  Chir.     iSS5. 

xii.,  p.  147. 
Briddon. — New  York  Med.  Journ.     Jan.  31st,  1885. 
Phila.  Med.  News.     1885.     xlvi.,  p.  115. 
Brun. — Cholecystotomy.     Arch.  g^n.  de  med.     1885.     i.,  p.  200. 
Buchanan. — Cholecystotomy.     Brit.  Med.  Journ.     1886.     i.,  p.  872. 
CoLzi. — Surgery  of  Biliary  Passages.     Sperimcntale.     Florence.     1886.     Ivii., 

pp.  225,  337,  457. 
Creyx. — D'lin  nouveau procedd  op.  des  Kystes  hydat.  du  joie.     Par.,  1881. 
Croft. — Hepatotomy.     Hyd.  Cyst.     Med.  T.  and  (jaz.     1883.     ii.,  p.  597. 
Curnow  and  J.  Smith.— Hepatic  Abscess.     Cases.     Lancet.     Jan.  2nd,  1886. 
Cyr. — Cholecystotomy.      Union  med.     1885.     xxxix.,  p.  109. 
Eddowes. — Cyst  of  Liver,  Laparotomy.     Brit.  Med.  Journ.     1884.    i.,  p.  410. 
Elsner.— Cholecyst.  for  Abscess.     Buffalo  Med.  and  Surg.  Journ.     July,  1887. 
Gardner. — Cholecystotomy.     Austral.  Med.  Journ.     1884.     vi.,  p.  34. 
Gaston. — Brit.  Med.  Journ.     1885.     i.,  p.  324. 

Duodeno-cholecystotomy.     Phila.  Med.  and  Surg.  Rep.     Sept.  12th, 


BIBLIOGRAPHY,  785 

Gould  (Keetley). — Cholecystotomies.     Annals  of  Surgery.     Oct.,  1888. 
Hacker. — Operative  Fixation  of  Movable  Liver,  &c.    Wien.  vied.  Woch.    1886. 

xxxvi.,  pp.  485,  529. 
Hayes. — Hepat.  Abscess.     Joiirn.  Amer.  Med.  Ass.     Nov.  28th,  1885. 
Hutchison. — Cholecyst.     Phila.  Med.  News.     1886.     xlviii.,  p.  509. 
Idelson. — Abstract  of  Cases  of  Movable  Liver.     Loiid.  Med.  Rec.     Aug.  15th, 

1885. 
Jacobi. — Hyd.  Cyst.     Removal.     Tr.  N.  Y.  Path.  Soc.     1879.     iii.,  p.  8. 
Jones. — Hydatid  Cyst  of  Liver.     Incision.     Med.  Chron.     1886.     iv. ,  p.  36, 
Keen. — Cholecyst.     Case.     Phila.  Med  Times.     Nov.  14th,  1885. 
KiRCHNER. — Zur.   operat.     Behand.    der   Leber-Echinococcen,       Berl.    Klin. 

Woch.     1880.     xvii.,  p.  315. 
Kohl, — Cholecyst.     Gorresp.  El.  f.  Schweiz.  Aertze.     1886.     xvi.,p.  193. 
Landau. — Die  Wanderleber,  &c.     Berlin.     1885. 

Landerer. — Cholecyst.     Case.      Mitnchen  med.  Woch.     1886.     xxxiii,  p.  297. 
Lange. — Cholecyst.     New  York  Med.  Joitrn.     Jan.  23rd,  1886. 
Langenbuch. — Berl.  Klin.  Woch.     18S6.     xxii. ,  p.  691. 

Berl.  7ued.  Gesellsch.     Jan.  26th,  1887. 
McGiLL. — Cholecystotomy.     Case,     Lajicet.     1884.     "•■  P-  873, 

Abscess  of  Liver,     Lancet.     Jan.  14th,  1888. 
Musser  and  Keen. — Cholecyst.     Amer.  Journ.  Med.  Sc.     Oct.,  1884. 
Napier. — Cholecystotomy.     Glasg.  Med.  Journ.     1886.     xxvi.,  p.  299, 
Ohage. — Cholecystotomy  (one  case)  and  Cholecystectomy  (one  case).     Phila. 

Med.  News.     Feb.  19th  and  26th,  1886. 
OsLER. — Tapping  the  Gall-bladder,     Med.  News.     Phila,     1882.     xli.,  p.  3S0. 
Parkes. — Cholecyst.     Case.     Amer.  Journ.  Med.  Sc.    July,  1885, 
Petit. — Mem.  de  I'Acad.  Roy.  de  Chir.     Tome  i.,  p,  163. 
PosNER, — Deutsche  med.  Woch.     1885.     xi.,  p.  45. 
Poulet. — Hydatids  of  Liver.     Rev.  de  Chir      No,  6,     1886.     p.  441. 

,,  ,,  Ball,  et  mem.  de  la  Soc.  de  Chir.  de  Par.     i885. 

xii.,  p.  129. 
Ranke. — Sixth  Congress  of  Germ.  Surg.     1877. 

Ransohoff. — Cholecyst.  Hepat.     Cases.     New  York  Med,  Rec.    1882,    p.  25S, 
RoBSON  (M.AYo). — Cholecyst.     Cases,     Lancet.     Oct,  31st,  1885, 
Sheaffer. — Trans.  Med.  Soc.     Renn.     1884.     xvi.,  p.  474. 
Tait. — Surg.  Treatment  of  Gall-stones.     Lancet,     Aug.  29th,  1885. 
Dis.  of  Ovaries,     p.  335. 

Hepatotomy.     Brit.  Med.  Journ.     1880.    ii.,p.  975,    And  1881.    ii.,p.  Si. 
And  Birm.  Med.  Rev.     1881.     iv.,  p.  343. 
Taylor  (J.  W.)— Cholecystotomy.     Brit.  Med.  Journ.     Jan.  21st,  1888. 
Terrier. — Kyste  hydatique  du  foie,     Laparotomie,     Bull.  Soc.  de  chir.      1886. 

xii. 
Thornton. — Hepat.  for  Hydatids.     Cases.     Med.  Times  and  Gaz.     1SS3.     i., 

p.  89. 
Truc. — Etitde  hist,  et  crit.  du  traitement  chir.  des  Kystes  hyd.  du  foie.     Par.,  18S1. 
Ughetti. — Supp.  Hepatitis.     Lond.  Med  Rec.     June,  1885. 
Whittaker. — Abscess  of  Liver.     Cincin.  Lancet.     Oct.  loth,  1885. 
Witzel. — Indications  for  Cholecyst.     Deutsche  Zeit.  f.  Chir.     Bd.  xxi.     Hft. 

I  and  2. 


OPERATIONS   ON   THE   SPLEEN. 

Arnison. — Brit.  Med.  Journ.     1878.     ii.,  p.  723. 
Bean. — Med.  Times  and  Gaz.     1867.     ii.,  p.  628. 

Ibid.     1868.     i.,  p.  278. 
Besancon, — Kyste  hydatique  de  la  rate.     Prog,  vied.     1S86,     iv,,  p.  85; 
Billroth,  —  Wien.  vied.  Woch.     1877,     No,  5. 

Lancet.     June  7th,  1884, 
Blum, — Archiv.  gen.  de  med,    June,  1883. 

51 


786  BIBLIOGRAPHY. 

Browne. — Lancet.     1877.     ii.,  p.  310. 

Bryant. — Ibid.     1867.     ii.,  p.  608. 

COATES.— (Abscess.)     Brit.  lUcd.  Journ.     1884.     ii.,  p.  143. 

Collier.— (Table  and  References.)     Lancet.     1S82.     i.,  p.  219. 

FouBERT. — De  la  splenotomie  pour  tumenrs  de  la  rate.     Paris.     1886. 

Franzolinl — Wien.  vied.  Woch.     1883.     No.  20. 

FuHRER  and  LuDWiG. — (Experiments.)     Vierordt's  Archiv.     1855.    xiv.,p.  307. 

Gilson. — Rev.  de  Chir.     April,  1885. 

MoLLiERE. — Splenotomie.     (References.)     Diet.  Encyc.  des  Sc.  Med. 

Morse.— (Extirpation.)     West.  Lancet.     San  Francisco.     1882.     ix.,  p.  403. 

Mo?,i.^-R.— Deutsche  Med.  Woch.     1884.     No.  22. 

Myers. — Extirpation  of  Wandering  Spleen.     Journ.  Amer.  Med.  Ass.    April 

2nd,  1887. 
FkAN.—Gaz.  Med.  de  Paris.     1867.     P.  779. 
Thornton. — References  and  Cases.     Med. -Chir.  Trans.     Ixix.,  p.  407. 

Cases  of  Splenectomy.     Lancet.     1886.     i.,  p.  854. 
WiLKS.— BnY.  and  For.  Med. -Chir.  Rev.     1856.     ii.,  p.  231. 

Guy's  Hasp.  Rep.     Series  iii.     ii.,  p.  37. 
WiNOGRADOFF. — Rcv.  de  Chir.     1885.     p.  318. 

Wright, — Splenectomy.     Case.     Tables.     3Ied.  Chron.     Dec.  1888. 
YouNKiN. — Amer.  Med.  Journ.     July,  1884. 
Zesas. — Langenbeek's  Archiv.     Bd.  xxviii.     P.  815. 


SUPRA-PUBIC   CYSTOTOMY. 

EARLY    AND    HISTORICAL. 

Pierre  Franco. — Petit  Traite  sur  les  Hernies.     1556.     (Re-impression  of  the 

first  edition  in  Rev.  de  Chirurg.     1884.) 
RoussETUS, — Traite    Nouveau  de  VHysterotomotoliie    ou    Enfantement    Cesarien. 

Paris.     1581  and  1596. 
HiLDANUS. — Treatise  on  Lithotomy.     Frankfort.     1682. 
Douglas  (John). — Lithotomia  Douglassiana  ;  or  a  new  method  of  cutting  for 

the  stone.     First  practised  by  John  Douglas,  F.R.S.,  Lithotomist  to  the 

Infirmary  at  Westminster.     London.     1723. 
Cheselden.— A  Treatise   on  the  High  Operation  for  the  Stone,   with  xvii. 

Copper-plates.     London.     1723.     (This  work  contains  also  translations 

from  the  writings  of  Roussetus,  Hildanus,  Tolet,  and  Dionis,  on  the 

high  operation.) 
Pye,  Samuel  (Surgeon  of  Bristol).— Some  observations  on  the  general  methods 

of  Lithotomy.     London.     1724. 
Middleton  (for  Thornhill,  Surgeon  of  Bristol).— An  essay  on  the  operation 

of  Lithotomy :    as  it  is  performed  by  the  new  method  above  the  os 

pubes.     London,  1727. 
Morand. — Traite  de   la   Taille   au   Haut   Appareil.     Paris.     1728.     Translated 

by  John  Douglas.     Lond.     1729. 
Heister. — Institutiones  Chirurgical.     Amsterdam.     1739. 

Couk-Frerk.— Nouvelle  me'thode  d'extraire  la  Pierre.     .     .     .     Brussels.     1779. 
Carpue. — History  of  the  High  Operation.     London.     1819. 

operations  for  stone. 

Albert. — Wien.  Med.  Presse.     1S76.     Nos.  4  and  5. 

Lehrbuch  der  Chir.     1883.     iv.,  p.  127. 
VoN.  Antal. — Eine  modificirte  sectio  alta.     Arch.  f.  klin.  Chir.     1SS5.     xxxii., 

p.  491. 
Assmuth.— Case.      Suture   of    bladder.      St.    Pefershurgh   Med.    Woch.     1SS6. 

iii.,  p.  411. 
Harwell. — On   Sup. -pub.   lithotomy.     Trans.     Roy.   Med  -Chir.  Soc.      188P. 

P-  341- 


BIBLIOGRAPHY.  787 

Belfield. — Sup. -pub.  cystotomy.    Case.    N.  Y.  Med.  Rec.  i8S6.    xxx.,  p.  197. 
Bond. — Adult ;  suture.     Primary  union.     Lancet.     1887.     i.,  p.  267. 
BouLEY. — Etude  historique  experimentale  et  critique  de  la  taille  hypogastrique. 

These  de  Paris.     1883.     No.  458. 
Chauvel. — Art.  Cystotomie.     Diet.  Encyc.  des  Sc.  Med.     xxv.,  p.  106. 
Croft. — Male,  72.     Cure.     Lancet.     18S7.     i.,  p.  267. 
CuLLiNGWORTH. — Woman.     Brit.  Med.  Journ.     1886.     ii.,  p.  1213. 
Dulles. — Amev.  Journ.  Med.  Sc.     1875.     ii.,  p.  39. 
Danhier. — De  la  taille  hypogastrique  chez  les  enfants.     These  de  Lille.     1885. 

No.  6. 
Dennis. — Supra-pubic  cystotomy.     Technique.     Phila.  Med.  News.     1887.     i., 

p.  589. 
Discussion. — Lancet.     1886.     i.,  p.  637. 
VoN  DiTTEL. — Gegen  die  Fiillung  der  blase  zum  hohen  Blasenschnitte.    Wien. 

med.  Woch.     1886.     xxxvi.,  p.  1505. 
DucKASTELET. — Quelqucs  points  de  la  taille  hypogastrique  en  France.     Ann. 

des  nialad.  gen.-urin.     1884.     ii.,  p.  555. 
Emson. — Lancet.     1887.     i.,  p.  1031. 
Flury  (Andreas). — Ein  Beitrag  zur  Geschichte  und  statistik  des  hohen  steinchnittes 

von  1854-7S.     Tubingen.     1S79. 
Garcin. — Contrib.  din.  a  I'ctiidc  de  la  cystotomie  sus-pubienne  avec  statistique  com- 

prenant  les  annees,  1879-83.     Strasbourg.     1884. 
Garson. — Dislocation  der  Harnblase  und  die  Peritoneum  bei  Ausdehnung  des 

Rectum.     Arch./.  Anatomic.     1878.     P.  171. 
Geister. — Advantages.     With  case.     N.  Y.  Med.  Journ.     1886.     xliii.,  p.  642. 
Gross  (Nancy). — De  la  cystotomie  sus-pubienne.      ,      .      .     Congris  Frangais 

de  Chir.     Paris.     1887.     p.  422. 
Gunther. — Der  hohe  Steinschnitt,  &c.     Leipzig.     1857. 
GuYON. — Ann.  des  Maladies  des  Org.  Urin.     Paris.     1883. 
Halle. — La  taille  hypogastrique,  &c.     Cinq  cas.     Paris.     1886. 
Howe. — Calculus  weighing  3541  grs.     Copenhagen  Congress. 
Hume. — Lancet.     1887.     i.,  p.  123. 

Jacobson. — Four  cases.     Med. -Chir.  Trans.     18S6.     Ixix.,  p.  377. 
Krabbel. — Ueber  antiseptische  Lithotomie.     Centralbl.  /.  Chir.     1881. 
Kuster. — Ueber    Harnblasengeschwulste,    &c.      Samml.    Klin.     Vort.      1S86. 

pp.  267,  268. 
Langenbuch. — Lithotomie  und  Antiseptik.     Arch,  f.klin.  Chir.     1881.     x.wi., 

p.  42. 
Langer. — Topographie   der   Mannlichen   Harnblase.      Zeit.  f.  Gesellsch.    der 

Aertze  en  Wien.     18S2.     p.  162. 
Lutrand. — Contrib.  d  I'etude  de  la  taille  hypogastrique.     Montpellier.     18S5. 
MacCormac. — Case.     Remarks.     Lancet.     1886.     ii.,  p.  582. 
McGiLL. — Three  cases.     Brit.  Med.  Journ.     18S7.     i.,  p.  17. 

Lancet.     1887.     i.,  p.  75. 
Mannheim. — Ueber  den  Hohensteinschnitt  bei  Kindern.     Berlin.     1885. 
Meyer.— Ueber  die  Nachbehandlung  in  hohen  Steinschnitts.     Arch.f.klin. 

Chir.     1884.     xxi.,  p.  502. 
Morgan. — Stone.     Hsem.  into  bladder.     Lancet.     1887.     i.,  p.  929. 
O'Hara. — Case.     Austral.  Med.  Journ.     1S87.     ix.,  p.  181. 
Orlowski.— Drei  Falle  von  hohen  Steinschnitt.     Deutsche  Zeit.  f.  Chir.     18S5. 

xxiii,,  p.  153. 
Paquet. — Taille  hypogastrique.     Bull.  med.  du  nord.     1886.     xxv. 
Patterson. — Med.  Press  and  Circ.     1^586.     xli.,  p.  311. 
Perier. — Mem.  a  V Academic  de  la  med.     Aug.,  1881. 

Bull,  et  mem.  Soc.  de  Chir.  de  Par.     1886.     xii.,  p.  935. 
Petersen. — Edin.  Med.  Journ.     Oct.,  1878. 
Pitts. — Med.  Press  and  Circ.     1S86.     xlii.,  p.  475. 
Pitts  (Bernard).— .^ycZ/fD./.  klin.  Chir.     1880.     xxv.,  p.  759. 
PiCARD.— Calcul    vesical    insaisissable,    taille    hypogastrique.      Gaz.   de   hvp. 

Paris.     1887.     Ix.,  p.  196. 

51    * 


788  BIBLIOGRAPHY. 

Preneux. — Etude  sur  la  taille  hypogastrique.     These  Lyon.     1885. 

PvE. — Two  cases.     Brit.  Med.  Jonni.     1886.     ii.,  p.  618. 

RiviNGTON. — Very  large  calculus.     Med.-CJiir.  Trans.     1886.     Ixix.,  p.  361. 

Roberts. — Phila.  Polyclinic.     18S6-7.     iv.,  p.  246. 

RosER. — Zur  Lehre  von  der  Sectio  Alta.   Arch.  f.  Klin.  Chir.    1SS6-7.    xxxiv., 

p.  441. 
RoBSON. — Two  cases.     Brit.  Med.  Joiirn.     1886.     ii.,  p.  1162. 
ScHMiTZ   (Arnold). — Erfahrungen   iiber   die  steinoperationen    au    Kindern. 

Archiv.  f.  klin.  Chir.     1886.     xxxiii.,  p.  427. 
See. — Etude  sur  la  taille  hypogastrique.    Rcv.de  Chir.    Par.    1887.    vii.,  p.  36. 
Smith  (Greig). — Stone,  9^  oz.     Bristol  Med.-Chir.  Journ.     Sept.,  1887. 
Smith  (T.) — Stone,  weighing  24^  oz.     Lancet.     1886.     ii.,  p.  399. 
Tuffler. — De  la  taille  hypogastrique.     Ann.  des  mal.  genito-urin.      1SS4.      iii., 

P-  367- 
Twyman. — Analyses  of  67  Cases.     Atistral.  Med.  Gaz.     Oct.,  1888. 
Valette. — De   la   taille   hypogastrique   pratiquee  au  nioyen  de    la  cauterization. 

Lyon.     1858. 
Walker. — Three  cases  in  boys.     Lancet.     1887.     i.,  p.  873. 
Whitehead. — Three  cases.     Lancet.     1887.     i.,  p.  1224. 
Znamensky. — Ueber  partielle  Resektion  der  Harnblasenwand.      Arch.  f.  klin. 

Chir.     1884.     xxxi.,  p.  1487. 

operations  for  tumour. 

Browne. — Fibro-papilloma.     Brit.  Med.  Joiirn.     1S87.     i.,  p.  204. 

Colles. — On  tumours  of   the  urinary  bladder  and   their  treatment.     Ann 

Surg.     St.  Louis.     1886.     iv.,  p.  208. 
FoLET. — Consideration  sur  le  traitement  des  tumeurs  de  la  vessie.     Bull,  med 

du  nord.     Lille.     1886.     xxv.,  p.  398. 
GuYON. — Various  papers  on  diagnosis,  and  treatment  in.     Ann.  d.  mal.  d.  org. 
genito-urin.     Par.     1886.     p.  651. 
Rev.  de  Chir.     Par.     1886.     vi.,  p.  938, 
Prog.  med.     1887.     v.,  p. .81. 
Hulke  and  Morris. — Cases  of  papilloma.  Med.  Press  and  Circ.  1886.  xlii.,  p.  45. 
Jones. — Papilloma.     Lancet.     1887.     ii.,  p.  65. 

Keyes. — Three  cases.     Jotirn.  Cut.  and  Urin.  Dis.     N.  Y.     1887.    v.,  p.  242. 
KusTER. — Sur  les  tumeurs  de  la  vessie  et  leur  traitement.     Samnil.  Klin,  Vortr. 

Leipz.     1886.     Nos.  267,  268. 
Lange. — Operation.     Phila.  3Ied.  News.     1886.     xlix.,  p.  639. 

Operation.     Papilloma.     N .  Y.  Med.  Joiirn.     Jan.  21st,  1888. 
Maracci. —  Operation.     Lo  Sperimentale.     1880.     xlvi.,  p.  350. 
Packard. — Trans.  Amer.  Med.  Assn.     May  nth,  1887. 

Paquet. — Operation.     Bull,  et  mem.  Soc.  de  chir.  de  Par.     1887,     xiii.,  p.  318. 
Pitts. — Operation  for  recurrence.     Trans.  Clin.  Soc.     1887.     p.  69. 
Smith  (Greig). — Four  cases.     Brit.  Med.  Journ.     1886.     i.,  p.  1161. 
Southam. — Operation.     Brit.  Med.  Journ.     1886.     ii.,  p.  715. 
Thompson  (Sir  Henry). — Tumours  of  the  Bladder.      1884.     And  papers  in 

Brit.  Med.  Journ.     1887.     i.,  p.  204. 
1888.     Jan.  7th  and  14th. 

Lancet.     1886.     i.,  p.  293. 

Clin.  Soc.  Trans.     1887.     P.  63. 
Wenning. — Cincin.  Lancet-Clinic.     Oct.  29th,  1887. 

OPERATIONS     FOR    ABDOMINAL    INJURIES     AND 
INFLAMMATIONS. 

gunshot    and    penetrating    wounds    and     RUPTURE    OF    VISCERA. 

Abbe.— iV.  Y.  Med.  Journ.     1886.     xliv.,  p.  564. 

Annals  of  Surg.     Dec,  1886. 
Barker. — Two  cases.     Brit.  Med.  Journ.     Mar.  17th,  1888. 


BIBLIOGRAPHY. 


789 


xli.,  p.  134, 
266. 


Oct. 


1887. 
P.  107 


Briddon. — N.  Y.  Med.  Jouvn.     1887.     i.,p.  75. 
Brooks. — Med.  Herald.     Louisville.     1886.     viii.,p.  134. 
Bryant. — Med.  News.     Phila.     Nov.  27th,  1886. 

Gaillai'd's  Med.  Journ.     New  York.     1886. 
Bull. — Boston  Med.  and  Surg.  Journ.     1886.     cxv. ,  p, 

Annals  of  Surg.     Dec,  1886. 

Phila.  Med.  News.     1886.     xlix. ,  p.  525. 
Carson. — jfourn.  Amer.  Med.  Assn.     Nov.  5th,  1887. 
CoLEY. — Boston  Med.  and  Surg,  jfourn.     Oct.  loth,  1888. 
Curtis. — Rupture  of  Intestine.     Internal.  Journ.  Med.  Sc. 
Dalton. — Stomach  and  Liver.     Tr.  Med.  Ass.  Missouri. 
Dennis. — Phila.  Med.  News.     1886.     xlviii.,  pp.  225,  253. 
Gaston. — Med.  and  Surg.  Rep.     Phila.     1886.     liv. ,p.  739. 
Grindon. — Am.  Journ.  Med.  Sc.     Jan.,  1885. 
Jersey. — N.  Y.  Med.  Rec.     1886.     xxx.,  p.  433. 
Kocher. — Corresp.  Bl.  f.  Schweiz.  Aertz.     xxiii.  and  xxiv. 

Lange. — Laparotomy  for  Bullet-wound.   N.  Y.  Med.  Journ.    Nov,  26th,  1867. 
Lloyd. — Brit.  Med.  Journ.     March  24th,  1883. 
LuTZ. — Med.  Rev.     St.  Louis.     1886.     xiv. ,  p.  514. 
MacCormac    (Sir   W.) — Abd.    Sect     for    Intra-perit. 

Lond.     1887. 
McGr.aw. — N .  Y.  Med.  Rec.     xxxii.,  9. 
Morton. — Journ.  Amer.  Med.  Ass.     Feb.  26th,  1887. 
Nancrede. — Ann.  of  Surg.     June,  1S87. 
Park. — Phila.  Med.  News      1888.     liii.,  p.  116. 
Parkes. — Ann.  of  Surg.     Nov.,  1887. 
Richardson. — Neiv  Orleans  Med.  and  Surg.  Journ.     188 
Rockwell. — N.  Y.  Med.  Journ.     1886.     liii.,  p.  620. 
Sherry. — Successful  operation.     Annals  of  Surgery.     Oct.,  1888. 
Skelly.— .4«;;.  of  Surg.     July,  1887. 
Smith. — Journ.  Amer.  Med.  Ass.     Nov.  27th,  1886. 
Travers. — Injuries  of  the  Intestines.     Lond.     1812. 
Tremaine. — Phila.  Med.  News.     Nov.  27th,  18S6. 


Injury.     (References.) 


xiii.,  p.  867. 


SUPPURATIVE    peritonitis. 

Barchard. — N.  Y.  Med.  Journ.     Aug.  15th,  1885. 

Barlow  and  Godlee. — Lancet.     1885.     ii.,  p.  1143. 

Brien. — Tubercular  Peritonitis.     Cincin.  Lancet-Clinic.     Dec.  24th,  1S87. 

Byrd. —TraHs.  Am.  Med.  Ass.     Phila.,  1881. 

Chaput. — Journ.  de  vied.     1880. 

Discussion. — Obstet.  Gaz.     Cincin.     1886.     ix.,  p.  169. 

FiTZ. — Internal.  Journ.  Med.  Sc.     Oct.,  1S86. 

Grant.— il/^r?.  Press  and  Circ.     1886.     xli.,  p.  449. 

Hall. — N.  Y.  Med.  Journ.     1886.     xliii.,  p.  662. 

Heald. — Boston  Med.  and  Surg.  Journ.     Sept.  3rd,  1885. 

Hoffmann. —  IVien.  Med.  Presse.     1881.     xxii.,  p.  114. 

Jackson. — Am.  Journ.  Obstet.     1886.     xix.,  p.  645. 

Krafft. — Perforation  of  Vermiform  App.   Rev.  Med.  de  la  Suisse  Rom 

Kronlein. — Archiv.  f.  klin.  Chir.     18S6.     xxxiii.,  p.  2. 

KuEM.MELL. — Tubercular  Peritonitis.     Ccntralbl.  f.  Chir.     i 

Mackenzie. — Diagnosis  in  Perforative  Peritonitis.     Lancet. 

1888. 
Mk-rsh.— Med. -Chir.  Trans.     1S85.     p.  1S5. 
Mikulicz. — Samml.  klin.  Vortr.     1S85.     No.  262. 
Oberst. — Centralbl.  f.  Chir.     1S85.     xx. 
Owen. — Lancet.     Oct.  loth,  1885. 

Reeve. — Boston  Med.  and  Surg.  Journ.     18S6.     cxv.,  p.  329. 
Reuss. — Tubercular  Peritonitis.     Wicn.med.  Woch.     1887.     No.  3|. 
Schmidt. — Vrach.     St.  Petersburg. 


18SS 


7.     No.  25. 
Dec.  1st  and  Sth, 


790  BIBLIOGRAPHY, 

ScKWA'RTZ. — Centralbl.  f.  Chir.     1887.     p.  S22. 

Secheyron. — Du  trait.  Chir.  de  la  Peritonite  Tuberculeuse.     Noiiv.  Arclitv. 

d'Obsiet.  et  de  Gynec.     Nov.  25th,  18S7. 
Sinclair. — Pelvic   Abscess.      Two   Cases.      Med.  Chvon.      Nov.,    1887,    and 

Jan.,  1888. 
Steinthal. — Eighteen    cases    collected.       Beilage    Zum     Centralbl.  f.    Chir. 

Nov.  24th,  188S. 
Stewart. — Perforative  Peritonitis.     Med.Chron      Nov.  1SS7. 
Tait. — Obst.  Gaz.     Cincin.     1886.     ix.,  p.  393. 
Terrillon. — Semaine  mid.     Paris.     1886.     vi.,  p.  305. 
Treves. — Med. -Chir.  Tratis.     1885.     p.  174. 
Truc. — Traitement  Chir.  de  la  Peritonite.     Paris.     1886. 
Wharton. — N.  Y.  Med.  Journ.     1886.     xliii.,  p.  608. 


RUPTURE    FROM    INJURY. 

BouiLLY. — Bnll.  de  la  Soc.  de  Chir.     Aout  10,  1884. 
Waggener. — St.  Louis  Coiir.  Med.     1886.     xvi.,  p.  204. 

RUPTURE  OF  BLADDER — LAPAROTOMY. 

(For  other  references  see  Text.) 

Ball. — Annals  of  Surgery.     1885.     i.,  p.  67. 

Heath. — Trans.  Med. -Chir.  Soc.     1879. 

Holmes. — Lancet.     July  23rd,  1887. 

Lesur. — Paris,  1888. 

MacCormac. — Two  cases.     Lancet.     Dec,  nth  and  i8th,  i{ 

Sonnenberg.— B^;-/.  klin.  Woch.     1885.     p.  142. 

Walter. — Med.  and  Surg.  Rep.     Phila.     1862. 

WiLLETT.— S^.  Bart.'s  Hasp.  Rep.     1876. 


INDEX. 


Abdomen,  Topographical  Anatomy,  i 
Abdominal  Operations,  History  of,  49 

Nomenclature  of,  49 
Abdominal  Injuries  and  Inflammations,  695 
Abdominal  Parietes,  Growths  in,  37,  641 
Abdominal  Tumours,  Conditions  simulating, 

23 
Abscess  of  Kidney,  542 
Liver,  44,  577 
Ovary,  43 
Peri-nephric,  545 
Spleen,  44 
From  Stitches,  87 
Adenoma  of  Kidney,  33 
Allingham's  Modification  of  Colotomy,  465 
Amnion,  Dropsy  of,  40 
Amussat's  Operation  {see  Colotomy),  447 
Anaesthetics,  71 
Anastomosis,  Intestinal,  400 
Anatomy  of  Abdomen,  Topographical,  i 
Surgical,  of  Broad  Ligaments,  159 
Gall-bladder,  574 
Intestines,  406 
Kidneys,  499 
Liver,  572 
Pancreas,  625 
Spleen,  614 
Stomach,  342 
Uterus,  Gravid,  270 
Anderson — Structure  of  Intestines,  411,  413 
Antiseptics,  60 
Anus,  Artificial,  490 
Operations  for,  492 
Resection,  495 
Appendicitis,  Perforative,  738 
Operative  Treatment,  743 
Pathological  Anatomy,  739 
Symptoms,  741 
Appolito — Intestinal  Suture,  481 
Ascites,  38,  no 
Assistance  at  Operation,  59 


Atmosphere,  Purification  of,  54 
Ball — Modification  of  Colotomy,  463 
Bantock — Mortality  after  Ovariotomy,  122 

Early  operation,  123 

Hysterectomy,  236,  et  scq. 
Barker — Gastro-enterostomy,  400 
Barnes — Oophorectomy,  177 

Rupture  of  Uterus,  307 
Barrow — (Boyce)  Gastrostomy,  362 
Battey — Oophorectomy,  origin  of,  174,  175 

,,  Results  of,  204 

Battey's  Operation,  174 
Bed  and  Bedding  for  Patient,  55 
Bell  (John) — in  History  of  Ovariotomy,  119 
Bernays — Gastrotomy  for  Cancer,  378 
Bigelow — Mortality  of  Hysterectomy,  235 
Billroth — Pylorectomy,  389,  393 
Bishop — Clamp,  477 

Intestinal  Suture,  479 
Bladder,  Distended,  23 

Resection  of.  Partial,  693 

Rupture  of,  727 
Causes,  728 

Operative  Treatment,  731 
Pathological  Anatomy,  727 
Symptoms,  729 

Shot-wounds  of,  714 
Blundell — Advocate  of  Oophorectomy,  173 
Braun — Statistics  on  Operation  for  Invagina- 
tion, 434 
Breudel— Operation  for  Ectopic  Gestation, 

335 
Broad  Ligaments,  Anatomy,  159 
Papillomatous  Cysts,  1C6 

Diagnosis,  16G 

Removal,  168 
Simple  Cysts,  162 

Diagnosis,  163 

Removal,  164 

Tapping,  163 
Brown  (Baker)— Influence  on  Ovariotomy,  121 


792 


INDEX. 


Bryant — Gastrostomy,  365 

Colotomy,  448,  d  seq. 
Bull  (W.  T.)— Gastrotomy,  377 

Gunshot  Wounds,  696 
Butlin — Ovariotomy  for  Malignant  Disease, 
156 

Resection  of  Intestine,  473 

Cascectomy,  470 
Caecitis,  738 
Caecum,  Cancer  of,  35 
Cassarean  Section,  273,  275 

FcEtus,  Extraction  ot,  278 

Hasmorrhage  in,  302 

History,  273 

Incision  in  Parietes,  276 
In  Uterus,  277 

Indications  for,  297,  304 

Modifications  of,  283 

Mortality,  298 

Peritonitis  after,  302 

Pregnancy  after,  302 

Shock,  301 

Uterine  Wound,  Treatment  of,  279 
Calculous  Suppression  of  Urine,  546 
Calculus,  Renal  {see  Nephro-lithotomy),  515 

Biliary  {see  Chole-lithiasis),  594 
Cancer  of  Cacum,  35 

Kidney,  33 

Pancreas,  30,  626 

Pylorus,  30,  390 

Uterus,  213 
Catgut  for  Ligatures,  65 
Catheterism,  55 
Cellulitis,  Pelvic,  757 

Cervix  uteri.  Amputation  of,  for  Cancer,  217 
Chambon — History  of  Ovariotomy,  iig 
Chavasse— Gastrostomy,  363 
Cheselden— Epicystotomy,  644,  646 
Cholecystectomy,  6n 
Cholecystotomy,  604 

History,  592 

Indications  for,  594 

Mode  of  Operating,  604 
Chole-lithiasis,  594 
Clamp,  Author's  Scissors,  78 

Author's  for  Broad  Ligaments,  224 

Keith's  Cautery-clamp,  138 

Keith's  Hysterectomy-clamp,  262 

Koeberle's,  248,  262 

Makins'  Intestinal,  476 

Tait's  Modification  of  Koeberle's,  248 
Clamp-forceps,  Wells's,  127 
Clarke  (Bruce) — Nephro-lithotomy,  528 
Clay  (Charles)— Ovariotomy,  History  of,  120 
Clothing  for  Patient,  55 
Clover's  Crutch,  217 
Cohn  —  Statistics   of  Malignant   Disease   of 

Ovaries,  156 


Cohnstein — Modification  of  Caesarean  Sec- 
tion, 283 
Colectomy,  471 
Colitis,  738 

Colon,  Growths  of,  450,  473 
Colotomy,  447 

History,  447 

Indications  for,  448 

Inguinal,  462 

Lumbar,  454 

Method,  choice  of,  451 

Mortality,  451 
Compressor,  Rope,  249 
Cousins — Tapping  Trocar,  116 
Covering  of  Patient,  57 
Curtis — Rupture  of  Intestine,  719 
Cystitis  after  Catheterism,  91 
Cystotomy,    Supra-pubic,    642    {see    Supra- 
pubic Cystotomy) 
Cystoma  of  Ovary  {see  Ovary),  30,  102 
Cysts  of  Broad  Ligaments,  40,  162,  166 

Extra-peritoneal,  638 

Kidney,  42,  533,  534 

Mesentery,  38,  637 

Omentum,  633 

Ovary,  30,  102,  183 

Pancreas,  38,  628 

Parovarian,  39,  162 

Spleen,  619 
Czerny — Intestinal  Suture,  482 

Delaporte — Ovariotomy,  History  of,  119 
Dermoid  Cysts  of  Ovary,  no 

Diagnosis,  112 
Diagnostic  Methods,  5 

Auscultation,  11 

Inspection,  5 

Palpation,  6 

Percussion,  9 

Puncture,  Exploratory,  11 

Scheme  of,  28 
Doran — Ovarian  Cystoma,  102,  104,  114 

Ovariotomy,  r42 

Growths  in  Broad  Ligament,  160,  162 
Douglas — History  of  Epicystotomy,  645 
Drainage,  80 
Drainage  tube — Keith's,  81 

Koeberle's,  82 
Dressings,  86 

Dropsy,  Encysted,  of  Peritoneum, 
Duodenostomy,  403 
Dupuytren — Intestinal  Suture,  480 


Ectopic  Gestation,  312 
Anatomy,  313 
Diagnosis,  318 
Indications  to  Operate,  322 


INDEX, 


793 


Ectopic  Gestation — Mortality,  322 
Operation,  Child  alive,  330 
Child  dead,  334 
Abdominal  Section,  329 

History,  312 
Electricity,  325 
Elytrotomy,  324 

Evacuation  of  Liquor  Amnii,  323 
Injection  of  Lethal  Substances,  324 
Removal  of  Sac,  329 
Rupture  of  Sac,  321,  329,  333 
Egebert— Gastrostomy,  345 
Elastic  Ligature  in  Hysterectomy,  263 
Enterectomy,   470  {see  Intestines,  Resection 

of) 
Entero-cholecystotomy,  609 
Enterorraphy,  479 
Enterotomy,  444 

Epicystotomy    642    {see    Supra-pubic    Cys- 
totomy) 
Epigastric  Region,  Contents,  3 
Epilepsy,  Operation  in,  191 
Examination  of  Patient,  General,  46 
Exploratory  Incision,  47 
Extra-peritoneal  Cysts,  638 
Extra-uterine  Pregnancy,  32,  41,  43,  312  {see 
Ectopic  Gestation) 

Faecal  Accumulations,  23,  429 

Faecal  Fistula,  490  {see  Artificial  Anus) 

Fallopian  Tubes,  Disease  of,  184 

Fluid  Collections  in,  43 

Pregnancy  in,  187 

Removal  of,  193 
Feeding  after  Operation,  89 

Rectal,  96 
Felizet— Gastrotomy,  370 
Fenger — Gastrostomy,  346 
Fibro-cystic  Disease  of  Uterus,  40 
Fibroma  of  Ovary,  31 
Fluid  Tumours,  37 

Symmetrica],  38 

Non-symmetrical,  42 
Forceps — Nelaton's,  127 

Sponge-holding,  78 

Tail's,  75 

Thornton's,  77 

Wells's,  75,  76,  77 

Galabin — Ectopic  Gestation,  335 
Gall-bladder,  Anatomy,  574 

Distension  of,  44 

Dropsy  and  Empyema  of,  596 

Gunshot  wounds,  714 

Operations  on,  592  {see  ChoJecystotomy, 
&c.) 

Perforation  of,  597 

Rupture  of,  734 

Solid  Tumours  of,  34 


Gall-stones,  594 

Sounding  for,  601 
Gardner — Operation,  Peritonitis,  94 
Garrigues — Laparo-elytrotomy,  292 
Garson — Epicystotomy,  664 
Gaston — Entero-cholecystotomy,  603 

Stab-wounds,  715 
Gastrectomy,  Partial,  388,  405   {see  Pylorec- 

tomy). 

Total,  404 
Gastro-enterostomy,  397,  398 

History,  397 

Indications,  397 

Mortality,  397 
Gastrorraphy,  380 

History,  380 

Indications,  380 

Operation  for  Fistula,  381 

For  Ulcer,  382 
Gastrostomy,  345 

Aim  of  Operation,  347 

Conditions    for    which    Operation    per- 
formed, 348 

Feeding  after,  367 

History,  345 

Mortality,  353 

Parietal  Incision,  358 

Stomach,  Fixation  of,  361 
Opening  of,  365 
Gastrotomy,  368 

History,  368 

Indications,  369 

Operation  described,  370 

For  removal  of  foreign  bodies  in  oesopha- 
gus, 375 
Godson — Caesarean  Section,  274 

Porro's  Operation,  285 
Gross — Gastrostomy,  353 

Gastrotomy,  368 
Gullet,  Absence  of,  350 

Stricture  of,  348 

Tumours  Outside,  349 

Ulceration  of,  350 
Gunshot  Wounds  of  the  Abdomen,  696 

Anatomical  Conditions,  697 

Indications  to  Operate,  703 

Mortality  after  Operation,  703 

Operation  for,  705 

Symptoms,  700 

Treatment  after  Operation,  717 
Gussenbauer — Cancer  of  Pylorus,  390 

Intestinal  Suture,  482 
Gusserow    Hysterectomy  for  Myoma,  236, 245 
Gut,  Silk-worm,  66 

Haematocele,  Pelvic,  Suppurating,  757 
Haemato-kolpos,  41 
Haemato-metra,  41 


794 


INDEX. 


Hffimato-salpinx,  43 
Hagedorn's  Needle  and  Holder,  86 
Hahn — Nephrorraphy,  511 
Halsted — Anatomy  of  Intestine,  411 

Intestinal  Suture,  483 
Hamburger — Auscultation  of  cesophagus,  352 
Hart — Ectopic  Gestation,  317 
Hegar — Oophorectomy,  174 

Hysterectomy  for  Myoma,  246,  260,  264 
Hepatic  Abscess,  44,  577 

Surgical  Treatment  of,  579 
Hepatotomy,  for  Abscess,  583 

For  Hydatids,  587 
Hevin — Intestinal  Obstruction,  415 

Nephrotomy,  516 
History  of  Abdominal  Surgery, 
Houston — History  of  Ovariotomy,  119 
Hunter — History  of  Ovariotomy,  119 
Hydatids  of  Kidney,  42,  534 
Liver,  44,  586 
Spleen,  620 
Hydramnios,  40 
Hydro-metra,  43 
Hydro-nephrosis,  42,  535 
Hydro-salpinx,  41,  186 
Hypochondriac  Region,  Contents,  3 
Hypogastric  Region,  Contents,  5 
Hysterectomy  for  Cancer,  210 
Freand's  Method,  210 
History,  210 

Indications  and  Contra-indications,  213 
Mortality,  211 
Operation  described,  219 
For  Intractable  Inversion,  232 
History,  232 

Varieties  of  Operation,  233 
Immediate  removal,  233 
Gradual  removal,  233 
Compression  and  Excision  com- 
bined, 234 
For  Myoma,  235,  248 
History,  235 
Indications,  236 
Keith's  Operations,  254 
Shroeder's  Operation,  252 
Mortality,  235,  266 
Hysterectomy,    Puerperal,  285    {see  Porro's 

Operation) 
Hysteria,  Operation  in,  193 
Hystero-epilepsy,  Operation  in,  192 
Hysterotomy,   Puerperal,  273  {see  Csesarean 
Section) 

Iliac  Regions,  Contents,  5 
Incision,  Exploratory,  47 
Parietal,  Making,  71 
Closing,  84 
Instruments,  67 


Intestinal  Obstruction,  414 
Diagnosis  of,  423 
History,  414 

Indications  for  Operation,  429 
Laparotomy  for,  414,  432 
Modes  of  Operating — 

For  Foreign  Bodies,  443 
In  Intussusception,  441 
In  Strangulation  by  Bands,  &c.,  440 
In  Volvulus,  439 
Intestines — Anatomy,  Surgical,  406 
Gunshot  Wounds  of,  6g6 
Obstruction  of,  414  {see  Intestinal  Obstruc- 
tion) 
Physical  Examination  of,  20 
Auscultation,  21 
Inspection,  20 
Palpation,  20 
Percussion,  20 
Intestines— Resection  of,  470 
Clamps  for,  476,  477 
History,  470 
Indications,  472 
Mode  of  Operating,  475 
Mortality,  474 
Rupture  of,  719 
Diagnosis,  722 
Operation  for,  723 
Pathological  Anatomy,  719 
Symptoms,  701 
Intussusception  of  Intestines,  419 

Operation  in,  441 
Invagination  of  Intestines,  419,  441 
Irrigation  of  Cavity,  78 

Jejunostomy,  404 

Jessop — Ectopic  Gestation,  331 

Jones  (Sydney)— Gastrostomy,  347 

Kaltenbach— Hysterectomy  for  Myoma,  260 
Kehrer— Modification  of  Cassarean  Section, 

283 
Keith — Antiseptics,  60 

Drainage  Tube,  81 

Ovariotomy,  121,  138,  143 

Cysts  of  Broad  Ligament,  163 

Hytserectomy  for  Myoma,  235,  254,  262 
Kidney,  Abscess,  42,  542 

Adenoma,  33,  533 

Calculus,  518,  546 

Cancer,  33,  554 

Cysts,  42,  109,533,553 

Displaced,  33 

Excision  of,  550  {see  Nephrectomy) 

Floating,  33,  507 

Gunshot  wounds,  713 

Hydatids,  42,  534 

Incision  of,  540  {see  Nephrotomy) 


INDEX. 


795 


Kidney,  Injury  to,  560 

Movable,  33,  505 

Puncture  of,  533 

Sarcoma,  33,  553 

Scrofulous,  543 

Tumours,  33,  553 
Kidneys,  Anatomy,  499 

Physical  Examination  of,  14 

Operations  on,  505  (see  Nephrotomy,  &c.) 
Kleeberg — Elastic  Ligature,  260 
Knot  (Staffordshire),  140 
Koeberle — Forceps,  75 

Drainage  Tube,  83 

Serre-noeud,  248,  264 
Kolpo-hysterectomy,  210 

Clamp  for,  224 

Complications,  230 

Division  of  Broad  Ligaments  in,  223 

Drainage,  229 

History,  210 

Indications  and  Centra-indications,  213 

Manipulation  of  Uterus  in,  220 

Mortality,  211 

Operation  Described,  219 

Suture  of  wounds  in,  228 

Position  of  Patient  in,  220 

Preparation  of  Patient  for,  220 

Lange— Anatomy  of  Kidneys,  504,  526 
Langer— Anatomy  of  Bladder,  663 
Langenbuch— Nephrectomy,  567,  570 

Cholecystotomy,  611 
Laparo-colotomy,  462 

Laparo-cystectomy,  329  {see  Ectopic  Gestation) 
Laparo-elytrotomy,  291 

Assistance,  292 

Child,  Delivery  of,  295 

Haemorrhage,  302 

History,  291 

Incision  through  Parietes,  293 

Indications,  297,  303 

Peritonitis  after,  302 

Pregnancy  after,  302 

Preliminary  Steps,  292 

Suturing  Wound,  295 

Vaginal  Opening,  293 
Lembert— Intestinal  Suture,  374,  482 
Leopold — Malignant  Ovarian  Growths,  155 

Caesarean  Section,  281 
Ligature,  Materials,  65 

Elastic,  260 

Interlocking,  141 
Light  during  Operation,  59 
Littre's  Operation,  447  {see  Colotomy) 
Liver,  Abscess,  44,  577 

Anatomy,  Surgical,  572 

Cancer,  34 

Gunshot  wound    of,  712 


Hydatids,  44,  586 

Physical  Examination  of,  i3 

Solid  Growths,  34 
Lloyd  (Jordan) — Nephro-lithotomy,  520,  et  seq. 
Loreta's  Operation,  384 

Aim,  384 

History,  384 

Pyloric  Obstruction,  385 
Lucas — Nephro-lithotomy,  52S 
Lund — Instruments  in  Colotomy,  458 


McArdle — Pylorectomy,  392 
MacCormac — Rupture  of  Bladder,  727 
Macdonald  (Angus) — Ectopic  Gestation,  335, 

337 
McDowell  (Ephraim)  —  History   of  Ovario- 
tomy, 119 
Madelung — Modification  of  Colotomy,  461 
Makins — Clamp  in  Enterectomy,  476 
Mania,  Operation  in,  191 
Martin — Tubal  Disease,  185 
May  (Bennett) — Nephro-lithotomy,  5 
Menses,  Retained,  41 

Obstruction  to  flow  of,  190 
Mesentery,  Cysts  of,  38,  637 

Lipoma,  637 

Solid  Growths,  636 
Mikulicz,  391 

Minges — Nephrectomy,  553 
Missed  Labour,  337 

Anatomy,  337 

Diagnosis,  338 

Operation,  338 
Molar  Pregnancy,  32 
Morris  (Henry) — Pylorectomy,  391 

Nephrorraphy,  511 

Nephro-lithotomy,  515,  et  seq. 
Morton — Gunshot  wounds,  703 

Stab  wounds,  715 

Perforating  Typhoid  Ulcer,  751 
Myoma  of  Ovary,  31 
Myoma  of  Uterus,  31,  188,  199,  238 

Diagnosis,  238 

Hysterectomy  for,  235 

Removal  of  Uterine  Appendages  for,  188, 
199 
Myomectomy,  240,  243 

Nelaton's  cyst-forceps,  127 

Nelaton's  Operation  {see  Enterotomy),  444 

Nephrectomy,  551 

Abdominal,  567 

History,  551 

Indications,  551,  558 

Lumbar,  563 

Method,  Choice  ot,  569 

Mortality,  5  7 


796 


INDEX. 


Nephric  Abscess,  43,  542 
Nephritis,  Suppurative,  542 
Nephro-lithotomy,  515 

History,  515 

Indications,  524 

Mode  of  Operating,  525 
Nephrorraphy,  505 

Indications,  510 

Mode  of  Operating,  511 
Nephrotomy,  532,  541 

Indications  to  Operate,  547 

Operation,  548 
Nomenclature  of  Abdominal  Operations,  49 
Notta — Ectopic  Gestation,  334 
Nursing  of  Patient,  55 

Obesity,  25 

(Edema  of  Abdominal  Walls,  26 

CEsophagus  {see  Gullet),  Absence  of,  350 

Auscultation  of,  352 

Cancer  of,  348 
Diagnosis,  350 

Fibrous  Stricture,  349 

Foreign  Bodies  in,  Gastrotomy  for,  368 

Obstruction  in,  348 

Ulceration  of,  350 
Omentum,  Abscess  in,  636 

Cysts  of,  633 

Gunshot  wounds  of,  712 

Physical  Examination  of,  21 

Sanguineous  Tumours  in,  636 

Sarcoma  of,  636 

Tumours  in,  633 
Oophorectomy,  171 

Aim  of,  175 

Conditions  indicating,  178 

History,  172 

Mode  of  Operating,  193 

Progress  after  Operation,  201 
Operating  room.  Plan  of,  69 
Ovariotomy,  100,  124 

Abdominal  incision  in,  129 

Accidents  during,  14G 

Adhesions  in,  135 

After-treatment,  149 

Assistance,  124 

Drainage,  144 

Dressings,  145 

Emptying  Cyst,  133 

Foreign  Bodies  left,  148 

History,  118 

Indications  and  Contra-indications,  122 

Instruments,  125 

Mortality,  122 

Pedicle,  136 

Peritoneal  Cleansing,  143 

Suturing  Parietal  Wound,  145 
Ovaritis,  180 


Ovary — 

Abscess,  43 
Anatomy,  100 
Cancer,  31,  155 
Cystic  and  Cirrhotic,  183 
Cystoma,  39,  102 

Anatomy,  Pathological,  102 

Diagnosis,  105 

Rupture  of,  112 

Suppuration  in,  114 

Tapping,  116 

Twisting  of  Pedicle,  113 
Dermoid  Cysts,  110 

Diagnosis,  112 
Displacements,  181,  200 

Hernia,  181 

Prolapse,  182 
Encapsuled,  148 
Fibroma,  31,  155 
Myoma,  31,  155 
Sarcoma,  31,  155 
Solid  Growths  of,  31,  155 

Anatomy,  Pathological,  155 

Diagnosis,  157 

Operation,  157 

Pancreas,  Cancer,  30,  626 

Cysts,  38,  628 

Operations  on,  625,  630 
Mortality,  632 

Physical  Examination,  of  71 

Surgical  Anatomy,  626 
Papillomatous  Cysts  of  Broad  Ligament,  40, 

109,  166 
Parietes,  Growths  in  37 
Parietal  Incision,  71 

Closure  of,  84 
Parotitis   following   Abdominal    Operations, 

98 
Parovarian  Cysts,  39,  162 
Parry — Ectopic  Gestation,  312,  ct  seq. 
Patient,  Environment  of,  53 

General  Examination  of,  46 

Preparation  for  Operation,  56 
Pean — Pylorectomy,  389,  393 
Peaslee — Ovariotomy,  121 
Pedicle  in  Hysterectomy,  260 

Combined  Method,  266 

Extra-peritoneal  Treatment,  261 

Intra-peritoneal  Treatment,  260 

In  Ovariotomy,  136 

In  Removal  of  Uterine  Appendages,  196, 
Pedicle-twisting,  in  Ovarian  Cystoma,  113 
Perforation  of  Viscera,  697 
Peri-nephric  Abscess,  42,  545 
Peritoneum,  Cysts  of,  38 

Cysts  Outside,  638 

Encysted  Dropsy  of,  38,  108 


INDEX. 


797 


Peritoneum,  Solid  Growths  of,  36 

Toilet  of,  143 
Peritonitis,  after  Operation,  93 

Operations  for,  431 

Pelvic,  736 

Purges  in,  93 

Rupture  from  Blows,  718 

Stabbing  and  Incised  Wounds,  696 

Suppurative,  737 

Tubercular,  761 

Traumatic,  93 
Petersen— Anatomy  of  Bladder,  664 
Petit — Cholecystotomy,  592 
Phantom  Tumour,  24 
Polk — Anatomy  of  Gravid  Uterus,  270 
Porro's  Operation,  284 

Haemorrhage  in,  287,  302 

Mortality,  298 

Parietal  Incision,  286 

Pedicle  in,  287 

Peritonitis  after,  290,  302 

Placenta  in,  287 

Shock  after,  301 

Uterine  Opening,  2S6 
Pozzi's  Elastic  Tourniquet,  249 
Pregnancy,  40 

Extra-uterine,  31,  32,  40,  41,  42,  43,  312 

Molar,  32 
Prostatectomy,  684 
Pseudo-cyesis,  24 
Puerperal  Hysterotomy,  273  {see  Cassarean 

Section) 
Puerperal  Laparotomy,  306  {see  Rupture  of 

Uterus) 
Puncture,  Exploratory,  n 
Purgatives  after  Operation,  93 
Pylorectomy,  389 
Pylorus,  Cancer,  30 

Fibroid  Thickening,  30,  385,  388 

Intubation,  405 

Obstruction,  384 

Operative  Dilatation,   385   {see  Loreta's 
Operation) 

Resection  of,  389  (Pylorectomy) 
History,  389 
Indications,  389 
Mortality,  391 
Operation  described,  392 
Pyo-nephrosis,  42,  541 
Pyo-salpinx,  43,  184 
Pyrexia  after  Operation,  97 

Reel-holder,  66 

Reichel — Resection  of  Intestine,  474 

Renal  Abscess,  542 

Calculus,  518 

Cysts,  40,  42,  log,  533,  553 
Richardson — Gastrotoray,  376 
Rivington— Rupture  of  the  Bladder,  727 


Rockwitz — Gastro-enterostomy,  398 
Rokitansky's  Tumour,  115 
Roussetus — Caesarean  Section,  273 

Supra-pubic  Cystotomy,  644 
Rupture  of  Abscesses,  739 
Cysts,  112 
Gall-bladder,  734 
Intestine,  719 

Diagnosis,  722 

Operation,  723 

Pathology,  719 

Symptoms,  721 
Urinary  Bladder,  727 

Operation,  734 

Pathology,  727 

Symptoms,  729 
Uterus,  306 

Anatomy,  306 

Operation,  309 

Symptoms,  307 
Viscera,  Solid,  733 

Salin— Missed  Labour,  339 

Salpingectomy,  171 

Salpingitis,  184 

Sanger's  Modification  of  Cassarean  Section, 

281 
Sarcoma  of  Kidney,  33,  553 

Ovary,  31,  155 

Uterus,  32,215 
Schroeder — Myomectomy,  252,  et  seq. 
Schultze — Missed  Labour,  339 
Scissors,  72 
Screw  for  Myoma,  243 
Sedillot — Gastrostomy,  345 
Senn — Inflation  of  Hydrogen,  701 

Intestinal  Anastomosis,  400 

Operation  on  Pancreas,  625 
Serre-nceud,  Koeberle's,  248 
Shock  after  Operation,  88,  91 
Silk  for  Ligatures,  63 
Simulation  of  Abdominal  Tumours,  23 
Solid  Tumours,  29 

Non-symmetrical,  32 

Symmetrical,  30 
Spleen,  Abscess,  44,  618 

Anatomy,  Surgical,  614 

Cysts,  619 

Enlargements,  Solid,  35,  619 

Gunshot  wounds,  713 

Hydatids,  45,  620 

Lymphosarcoma,  619 

Operations  on,  614 

Physical  Examination  of,  16 

Prolapse,  619 

Wandering,  36,  619 

Wounds,  618 
Splenectomy,  622 

History,  616 


798 


^  INDEX. 


Splenectomy,  Indications  6i8 

Mortality,  620 

Operation  described,  622 
Sponges,  Preparation,  62 
Spray,  Antiseptic,  54,  60,  62 
Stab-wounds  of  the  Abdomen,  715 
Staffordshire  Knot,  140 
Stomach,  Anatomy,  342 

Cancer,  Removal  of,  378 

Gunshot  wounds  of,  712 

Morbid  Growths,  30 

Operations,  340  (see  Gastrostomy,  &c.) 

Operative  Dilatation  of  Orifices,  384 

Physical  Examination  of,  17 

Rupture  of  726 

Ulcer  perforating,  382,  749 
Anatomy,  747 
Operation  for,  382,  749 
Symptoms,  747 
Strong — Anatomy  oi  Bladder,  666 
Suppuration  in  Cysts  of  Ovary,  114 
Supra-pubic  Cystotomy,  642 

Anatomical  Considerations,  662 

Bladder  Distention  in,  673 

Foreign  Bodies,  Extraction  of,  683 

History,  643 

Incision  through  Parietes,  677 

Indications  for  Operation,  650 

Mode  of  Operating,  672 

Prostate,  Removal  of,  684 

Rectal  Distension  in,  664,  675 

Stone,  Extraction  of,  681 

Suture  of  Bladder,  686 

Treatment  after,  691 

Tumours,  Removal  of,  682 
Sutures,  65 

Intestinal,  479 

Vesical,  686 
Suture-instrument,  85 
Syringe,  Exhausting,  Tait's,  82 


Table,  Operating,  57,  70 

Tait  (Lawson) — Pseudo-cyesis,  25 

Catch-forceps,  75 

Exhausting  Syringe,  82 

Twisting  of  Ovarian  Pedicle,  113 

Ovariotomy  Mortality,  122 

Cyst-trocar,  128 

Staffordshire  Knot,  140 

Solid  Growths  of  Ovary,  155 

Removal  of  Appendages,  171,  et  seg. 

Screw  for  Myoma,  243 

Hepatotomy,  5S3,  590 

Cholecystotomy,  594,  ct  seg. 
Thomas's    Operation,    291    (see    Laparo-e'y- 

trotomy) 
Thorburn — Anatomy  of  Ureters,  209 


Thornhill — Supra-pubic  Cystotomy,  647 
Thornton — Antiseptics,  60 

Catch-forceps,  77 

Ovarian  Cells,  104 

Ovariotomy,  121,  142 

Ectopic  Gestation,  334 

Gastrotomy,  369,  372 
Tillaus— Regions  of  Abdomen,  3 

Anatomy  of  Stomach,  343 
Toilet  of  Peritoneum,  77,  143 
Tourniquet,  Pozzi's  Elastic,  249 
Treatment  after  Operation,  89 
Treves — Anatomy  of  Intestines,  409 

Intestinal  Obstruction,  416 

Intestinal  Clamps,  477 
Trocar,  Tait's,  128 

Wells's,  128,   129 
Tubercular  Peritonitis,  761 
Tumours,  Diagnosis  of  Abdominal,  i 
Twisting  of  Pedicle  in  Ovarian  Tumours,  113 
Tympanites,  26,  94 
Typhoid  Ulcer,  Perforating,  751 

Operation  for,  752 


Umbilical  Region,  Contents,  5 
Urachus,  Cysts  of,  42 

Sarcoma  of,  641 
Ureter,  Fistula  of,  556 

Modes  of  Catheterising  and  Compress- 
ing, 560 

Relations  of,  209 
Uterine  Appendages,  Physical  Examination 

of,  21 

Removal,  171 

Aim  of  Operation,  175 

History,  172 

Indications,  178 
Modes  of  Operating,  193 

With  Normal  Structures,  195 
"      Inflamed  Structures,  197 

For  Myoma,  199 

For  Ovarian  Hernia,  200 
Nomenclature,  171 
Progress  after  Operation,  201 
Effects  of  Operation,  202  ' 
Uterus — Anatomy,  Surgical,  205,  270 

Anomalies    and    Defects    in— Operation 

for,  190 
Cancer,  213,  215  (see  Kolpo-hysterectomy) 
Cancer,  Cervical  Amputation,  217 
Hysterectomy  for,  210 
Displacements,  Incurable,  190 
Fibro-cystic  Disease,  40,  109 
Gravid,  Anatomy,  270 

Operations  on,  268 
Intractable  Inversion,  232 

Hysterectomy  for,  234 


INDEX. 


799 


Uterus,  Myoma,  31,  188,  238 

Hysterectomy  for,  235,  243,  248 
Physical  Examination  of,  21 
Rupture,  306 

Anatomical  Conditions,  306 
Diagnosis,  307 
Operation  for,  309 
Sarcoma,  32 
Urinary  Fistula,  556 
Urine,  Calculous  Suppression  of,  546 

Vautrin — Hysterectomy,  for  Myoma,  235 
Verneuil — Modification  of  Colotomy,  462 
Visitors,  Presence  of,  54 
Vomiting,  92 


Volvulus  of  Intestines,  419 
Mode  of  Operating  on,  439 

Warmth  during  Operations,  58 
Wells — Antiseptics,  60 

Pressure  Forceps,  75 

Ovariotomy,  121 

Ascites  Tube,  117 

Clamp-forceps,  127 

Cyst-trocar,  128,  129 
Whitehead — Gastrostomy,  350 
Winslow — Pylorectomy,  391 
Wolfler— Pylorectomy,  389,  ct  seq. 

Zesas— Gastrostomy,  347 


J.  W.  Arrow-smith,  Printer,  Quay  Street,  Bristol. 


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